By Leon Chaitow N.D., D.O., M.R.O.
Author’s Note: The majority of the research discussed in this article derives from the USA where the distinction between Chronic Fatigue Syndrome (CFS) and Myalgic Encephalomyelitis (ME) is largely unknown, and since there is still disagreement amongst experts as to whether CFS is the same as ME or not – and it seems likely that this argument will run for some time – this text will therefore bracket the condition(s) as CFS (ME).
In marked contrast to the time it has taken for research into ME and CFS to emerge, there has over the past few years been an explosion in the medical literature featuring Fibromyalgia Syndrome (FMS).
The more the condition has been researched (FMS) the more obvious it has become that there is a vast overlap between it and ME/CFS.
The Most Common Symptoms Found in Fibromyalgia Are: (1,2,3,4)
• 100% of people with FMS have muscular pain, aching and/or stiffness (especially in the morning)
• Almost all suffer fatigue and badly disturbed sleep
• Symptoms are almost always worse in cold or humid weather
• The majority of people with FMS have a history of injury – sometimes serious but often only minor within the year before the symptoms started
• 70% to 100% (different studies show variable numbers) are found to have depression (though many consider that this is more likely to be a result of the muscular pain rather than part of the cause)
• 73% to 34% have Irritable Bowel Syndrome
• 56% to 44% have severe headaches
• 50% to 30% have Raynaud’s phenomenon (hands go dead white and cold)
• 24% suffer from anxiety
• 18% have dry eyes and/or mouth (Sicca syndrome)
• 12% have osteoarthritis
• 7% have rheumatoid arthritis
• An as yet unidentified number of people with FMS have had silicone breast implants and a newly identified Silicon Breast Implant Syndrome (SBIS) is now being defined
• Between 3 and 6% are found to have substance (drugs/alcohol) abuse problems
Other Conditions Which Are Extremely Common with Fibromyalgia Include:
Allergies, chronic rhinitis (almost constant runny nose), easy bruising, night cramps, restless leg syndrome, dizziness (sometimes caused by the widely prescribed anti-depressant medication given to help the sleep problems in FMS), sleep apnea (breathing seems to stop while asleep), dry eyes and mouth, bruxism (teeth grinding), extreme sensitivity to light (photophobia), premenstrual syndrome, digestive disturbances, viral infections, Lyme disease (resulting from tick-bite), itchy skin – with or without a rash, loss of hair, sensitive bladder, mouth ulcers, generalized muscular stiffness, ‘foggy’ brain (difficulty in concentrating and poor short term memory), dyslexia (wrong words come out or what is read is not understood), panic attacks, phobias, mood swings, irritability, a feeling of hands and feet being swollen without evidence of fluid retention.
The Official Definition of/criteria for FMS (5)
Many people suffer from generalized, muscular aching and pain, however this only officially becomes the medical condition labeled ‘Fibromyalgia Syndrome’ (FMS) when this aching muscle pain is accompanied by pain produced when pressure is applied to certain specific body areas. The most commonly accepted definition is that the person affected needs to show:
1. History of Widespread Pain
Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist and pain below the waist. In addition there should be pain in the spine or the neck or front of the chest, or thoracic spine or low back.
2. Pain in 11 of 18 Tender Point Sites on Finger Pressure
There should be pain on pressure (around 4kg of pressure maximum) on not less than 11 of the following sites:
• Either side of the base of the skull where the subocciptal muscles insert
• Either side of the side of the neck between the 5th and 7th cervical vertebra, technically described as between the ‘anterior aspects of inter-transverse spaces’
• Either side of the body on the midpoint of the muscle which runs from the neck to the shoulder (upper trapezius)
• Either side of the body on the origin of the supraspinatus muscle which runs along the upper border of the shoulder blade
• Either side, on the upper surface of the rib, where the second rib meets the breast bone, in the pectoral muscle
• On the outer aspect of either elbow just below the prominence (epicondyle)
• In the large buttock muscles, either side, on the upper outer aspect in the fold in front of the muscle (gluteus medius)
• Just behind the large prominence of either hip joint
• On either knee in the fatty pad just above the inner aspect of the joint.
Don Goldenberg, M.D., lists other similarities between fibromyalgia and chronic fatigue syndrome:(8)
There is no known cause
There are no highly effective treatments
There are chronic symptoms which include fatigue, myalgias, neurocognitive dysfunction, mood disturbances and sleep disturbances
The population most affected is women aged between 20 and 50
How Disabling is Fibromyalgia (FMS)?:
100 out of 394 patients (that is 25.3%) with FMS (all female) and 12 out of 44 males (27%) were shown in a recent survey to be sufficiently badly affected by the condition as to be unable to work – they were effectively disabled.(8a)
Almost all the others surveyed claimed that their FMS affected their job performance very badly. In Canada a single insurance company, London Life, reported in 1989 that it was issuing monthly long-term disability payments to over 630 people with a diagnosis of fibromyalgia – involving a total of around a million dollars a month.
Change the Name, Change the Attitude
An example of why the naming of a condition matters can be seen from the word ‘fibrositis’ the previously used name for fibromyalgia. When a word ends in ‘itis’ in medicine it signifies that there is an inflammatory process involved. No evidence has ever been produced that the muscular aches and pains of fibrositis and/or fibromyalgia have much to do with inflammation.
Anti-inflammatory drugs therefore do not influence the condition and because of this many doctors assumed that the condition was a fiction – and that the symptoms complained of were unimportant or were imaginary.
By changing its name to ‘fibromyalgia syndrome’ the ‘inflammation’ element was removed and with this came the possibility for research and a wider understanding of the processes involved. The change in name has been accompanied by a rash of research and review articles in the medical journals – with a few in 1985 but around 100 in 1990.
CFS (ME) and FMS: Are They the Same? (9)
There is disagreement amongst experts as to whether or not ‘fibromyalgia syndrome’ and ‘chronic fatigue syndrome’ are the same condition.
Both CFS(ME) and FMS often seem to begin after an infection or a severe trauma (physical or emotional) , and as indicated above the symptoms are very similar. The only obvious difference seems to be that for some people the fatigue element is the most dominant while for others the muscular pain symptoms are greatest (and for an unfortunate few both are markedly present).
In other words, for many people the diagnosis CFS(ME) and FMS seem to be interchangeable terms, although there are certain symptoms (fever, swollen glands for example) which are found in a higher percentage of CFS(ME) patients than those with FMS, which makes the comparison less precise.
Some doctors insist that the psychological aspects of these conditions [FMS as well as CFS(ME)] is the most important cause and they use the terms ‘masked depression’ and ‘somatoform disorder’ to describe such conditions. This is resented by those afflicted by CFS(ME) or FMS who see the psychological and emotional symptoms as being the result of their fatigue, pain and general ill health, and not as causes.
‘Foggy Brain’ Symptoms (10)
Memory lapses, inability to concentrate, dyslexic episodes [inability to recall simple words], are all part of many people’s fibromyalgia (and of most people’s chronic fatigue) and modern technology has now identified what may be happening in the brain with these conditions.
Among the abnormalities so-far found in the brains of many patients with FMS and CFS(ME) are reduced blood flow and energy production in key sites of the brain. While any such changes might themselves merely be symptoms of the syndrome it is thought by many researchers that the most important imbalance in these conditions probably lies in the brain and central nervous system itself.
New technologies for visualizing the brain in a non-invasive manner (SPECT, BEAM, PET) show that there are few if any differences in the scans of patients with CFS(ME) and FMS.
What’s Going on in the FMS Patient’s Muscles? (11,12,13)
A host of stress related adaptations and changes are likely to have taken place in the muscles of someone with fibromyalgia resulting from overuse, misuse, abuse or disuse (postural, occupational, leisure activity, repetitive use, trauma etc) plus a number of additional factors.
1. A biochemical imbalance which may be the direct result of disturbed sleep leads to inadequate growth hormone production and poor repair of minor muscle damage.
2. Low levels of a serotonin in the blood and tissues lead to lowered pain thresholds because of the reduced effectiveness of the body’s natural endorphin painkillers, and the increased presence of ‘substance P’ which increases pain perception.
3. The sympathetic nervous system, which controls muscle tone can become disturbed leading to muscle ischemia (oxygen lack) resulting in greater ‘substance P’ release and increased sensitivity.
4. Duna proposes that these two elements are combined in fibromyalgia. Disordered sleep leading to reduced serotonin leading to reduced natural pain killing effects of endorphins, combined with a disturbed sympathetic nervous system which has resulted in muscle ischemia and increased pain sensitivity. Both disturbances involve reduced pain thresholds and activation of latent trigger points, with muscle pain as the end result.
5. ‘Micro-trauma’ (tiny amounts of damage) of muscles occurs in FMS patients ( genetic predisposition is a possible cause) leading to calcium leakage which increases muscle contraction, further reducing oxygen supply. This seems to be associated with a reduction in the muscle’s ability to produce energy , causing it to fatigue and to be unable to pump the excess calcium out of the cells. A similar mechanism is said by Travell and Simons to be involved in myofascial trigger point activity. (11)
6. James Daley MD has tested just what happens in the muscles of people with CFS(ME) when they exercise. Tests involving people with FMS (by Robert Bennett MD) gave similar results showing that muscles produced a great amount of lactic acid, adding to the discomfort. Some of the patients showed low carbon dioxide levels when resting, which is an indication of a hyperventilation tendency.
There is some evidence that progressive cardiovascular training (graduated training through exercise) improves muscle function and reduces pain in FMS but this is not thought desirable (and is often quite impossible anyway because of the degree of fatigue) in CFS(ME). (12,13)
The special features of fibromyalgia seem to involve a combination of circulatory and nerve imbalances which make the muscle changes even more pronounced and the symptoms more unpleasant.
Manual therapy, nutrition, stress reduction, breathing and postural reeducation, exercise (in some cases), acupuncture, non-specific immune system modulation such as hydrotherapy , medication (herbal, homeopathic and standard), among other things, have all been useful in encouraging recovery.
Dr. Goldenberg has shown that the following methods all produce benefits in treatment of FMS:(17)
Cardiovascular Fitness Training (18)
Regional Sympathetic Blockade (21)
Cognitive Behavioural Therapy (22)
My Own Protocol
Where a condition has multiple interacting causes it makes clinical sense to try to reduce the burden of whatever factors are imposing themselves on the defense, immune and repair mechanisms of the body, while at the same time doing all that is possible to enhance those mechanisms.
In my own practice the following are the methods suggested and used in treatment of FMS not necessarily in the order listed:
1. It is vital to get the diagnosis right. Many other rheumatic- type problems can produce widespread muscular pain such as polymyalgia rheumatica. Laboratory and other medical tests can identify most conditions which are not FMS.
2. Where muscle pain exists it is necessary to discover how much of the problem might be related to myofascial trigger point activity since the pain from trigger points is relatively easy to eliminate using methods chosen from injections, acupuncture, bodywork and postural and/or breathing reeducation.
3. It is important to assess and treat any associated conditions such as allergy, anxiety, hyperventilation, yeast or viral activity, bowel dysfunction, underactive thyroid, sleep disturbance.
4. It is useful to introduce constitutional health enhancement methods such as breathing retraining, deep relaxation methods (e.g., autogenic training ) regular (weekly or fortnightly) detoxification (fasting) days (which boost growth hormone production), hydrotherapy (neutral bath for anxiety and possibly progressive cold bathing), regular non-specific massage and acupuncture for ‘energy balancing’ and pain control.
5. Provision of suitable nutritional advice in important as well as use of supplements if necessary, such as specific amino acid supplementation for stimulating growth hormone production
6. Specific herbal help for circulation to the brain [e.g., Ginkgo biloba] and the taking of homoeopathic remedies such as Rhus tox 6C may be useful
7. Appropriate osteopathic soft tissue treatment of the muscular condition, as well as regular (daily if possible) gentle self- treatment methods are usually helpful
8. Regular exercise within tolerance, if possible including cardiovascular training and stretching movements (yoga and/or T’ai chi)
9. Medication under medical advice only, to enhance sleep patterns may be worth considering, antidepressant drugs in very low dosage commonly give some benefit
10. Patients should be encouraged to join support groups, and to read about their condition and health enhancement, and to take control of their condition, even if progress is apparently slow. Stress or general counseling may help them learn coping skills and stress reduction tactics.
1. Sydney Block Fibromyalgia and the Rheumatisms Controversies in Rheumatology Vol19(1)1993pp61-78
2. Don Goldenberg Fibromyalgia, chronic fatigue syndrome and myofascial pain syndrome. Current Opinion in Rheumatology 5:199-208 1993
3. George Duna and William Wilke Diagnosis, etiology and therapy of fibromyalgia Comprehensive Therapy 19(2)60-63;1993
4. Bruce Rothschild Fibromyalgia : An explanation for the aches and pains of the nineties Comprehensive Therapy 17(6):9-14 1991
5. Wolfe F et al The American College of Rheumatology 1990 Criteria for the classification of Fibromyalgia Report on Multicentre Criteria Committee Arthritis Rheum 33:2;160-172, 1990
6. Block S. op cit
7. Yunus M . ‘Fibromyalgia and other functional syndromes’ Journal of Rheumatology 16(sup 19)69 1989
8. Goldenberg D. ‘Fibromyalgia and its relationship to chronic fatigue syndrome, viral illness and immune abnormalities’. Journal of Rheumatology 16(sup 19)92 1989.
8a. Goldenberg D Presentation to the 1994 American College of Rheumatology meeting.
9. Harvey Moldofsky Fibromyalgia, sleep disorder and chronic fatigue syndrome. Ciba Foundation Symposium 173 Chronic Fatigue Syndrome p 262-270 1993.
10. As reported in Fibromyalgia Network (May 1993 Compendium, July 1993, January 1994).
11. David Simons Fibrositis/fibromyalgia A form of myofascial trigger points ? American Journal of Medicine 81(suppl 3A)pp93-98.
12. Report in Fibromyalgia Network May 1993 Compendium on First national Seminar for patients, Columbus Ohio, April 1990 (Robert Bennett MD presentation on muscle microtrauma – pages 23 – 25).
13. Report in Fibromyalgia Network (Compendium 2 pp48-49) on 2nd Los Angeles CFIDS Conference may 18/19 1991.
14. Frederick Wolfe, David Simons et al The Fibromyalgia and myofascial pain syndromes Journal of Rheumatology 1992;19:6pp944-951.
15. Vladimir Janda Muscles and Cervicogenic pain and syndromes. from Physical Therapy of the cervical and thoracic spine Ed.R.Grant Churchill Livingstone London 1988 pp153-166.
16. Gwendolen Jull and Vladimir Janda Muscles and Motor Control in Low Back Pain Physical Therapy of the low back. from Physical Therapy of the low back Ed.Lance Twomey Churchill Livingstone London 1987 pp253-278.
17. Goldenberg D Fibromyalgia : Treatment programs J of Musculoskeletal Pain Vol.1 3/4 1993 pp71-81.
18. McCain G et al Controlled study of supervised cardiovascular fitness training program Arthritis Rheum 31:1135-1141 1988.
19. Ferraccioli G et al EMG-Biofeedback in fibromyalgia syndrome J. Rheumatology 16;1013-1014 1989.
20. Haanen H et al Controlled trial of hypnotherapy in treatment of refractory fibromyalgia J Rheum 18:72-75 1991.
21. Bengtsson A et al Regional sympathetic blockade in primary fibromyalgia Pain 33; 161-167 1988.
22. Goldenberg D et al Impact of Cognitive-behavioural therapy on fibromyalgia Arthritis Rheum 34(suppl9):S 190, 1991.
23. Stoltz A Effects of OMT on the tender points of FMS Report in Journal of American Osteopathic Association 93(8)p866 August 1993.
24. Lo K et al Osteopathic Manipulative Treatment in Fibromyalgia syndrome J American Osteopathic Association (abstract) 92(9)1177 1992.
© 1995-2003 Leon Chaitow N.D., D.O., MRO
Senior Lecturer, University of Westminster