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Physician Interview: William Salt, M.D., and Edwin Season, M.D., on Treating Fibromyalgia

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William B. Salt II, M.D., is board-certified in both internal medicine and gastroenterology. He received his M.D. degree from The Ohio State University in Columbus, Ohio, in 1972, where he currently holds an appointment as Clinical Associate Professor in Medicine. He trained for five more years in internal medicine and gastroenterology at Vanderbilt University Hospitals in Nashville, Tennessee, where he also served as a Chief Resident in Medicine.

Edwin H. Season, M.D., is board-certified in orthopedic surgery. He received his M.D. degree from The Ohio State University in Columbus, Ohio, in 1971, followed by internship at the University of Virginia. He then returned to Ohio State for his residency and upon its completion, taught orthopedic surgery as an assistant professor in The Ohio State University College of Medicine from 1976 to 1980.

Before we begin, I (Dr. Salt) must issue a disclaimer. I am a gastroenterologist, which is a subspecialty of internal medicine in digestive and liver disease. I became interested in fibromyalgia, because up to two thirds of patients with functional gastrointestinal disorders – and irritable bowel syndrome in particular – also suffer with fibromyalgia. Science is confirming that these conditions share a common link, which is a disturbance or “dysregulation” in the central nervous system and in the connections between brain and body.

The reason that the digestive tract (or gut) is so commonly involved in this dysregulation is that there are two brains in the body and they are connected. One is the brain within the skull and is part of the central nervous system, or CNS. There is a second brain in the lining of the gastrointestinal tract called the enteric nervous system, or ENS.

Dr. Jack Wood, a renowned physiologist at The Ohio State University calls the ENS “the little-brain-in-the-gut.” The CNS and ENS closely resemble one another, because they both develop from the same embryonic tissue. Later, they take different developmental paths, but they continue to have similar nerve tissue and neurochemical communication receptor sites. All of the neurochemicals in the CNS are also found in the ENS (e.g., serotonin). The two brains function independently and interdependently and mutually influence one another. The brain affects the gut and the gut affects the brain.

This is the mind/brain-gut connection, and when there is malfunction of the connection, functional symptoms that result in functional diagnoses, such as irritable bowel syndrome can occur.

I believe that people are overwhelmed and confused by information – and much of it is misinformation – about their problems and that it is difficult for them to find comprehensive, contemporary and scientifically-based information that can be translated into knowledge (since information and knowledge are not the same).

Furthermore, even if doctors shared a common understanding of functional symptoms and disorders (and they do not), most generally do not have sufficient time to provide adequate patient education and assist patients to help themselves.

With this in mind, I have invited a well-respected musculoskeletal specialist to coauthor the answers here. Ed Season, M.D., is an orthopedic surgeon with a special interest in helping people without surgery. He is my coauthor in the book, “Fibromyalgia and the MindBodySpirit Connection.” You have described fibromyalgia (FM) as a functional illness. Please explain what that means for patients seeking appropriate treatment.

Bill Salt, M.D.: The medical term, “functional” refers to a disturbance in how the body works. Medical tests, such as X-rays, endoscopy, and blood tests either fail to explain the symptoms or show findings that are not the cause of the problem. All too commonly, a functional diagnosis leads to patient – physician misunderstanding, with the patient either thinking or saying, “Do you mean that the problem is all in my head?” We will examine this premise later in the interview. Many of our readers are confused by the sometime classification of fibromyalgia as an autoimmune disease. Do you think FM is an autoimmune disorder?

Bill Salt, M.D.: No. On the website of the University of Michigan Chronic Pain & Fatigue Research Center (, Dr. Dan Clauw and colleagues discuss the differential diagnosis of fibromyalgia. Fibromyalgia may present similarly to a number of disorders or concurrently (at the same time) with other disorders – such as autoimmune disorders – that may confuse the diagnosis. Unlike fibromyalgia, autoimmune diseases include inflammation of the synovial membranes that line the spaces between bones and joints and secrete a thick, lubricating fluid. In addition to the primary symptom, pain, fatigue, refreshing sleep and IBS are common problems for FM patients. How do you go about treating these symptoms – do you utilize both traditional and alternative therapies? If so, what has worked best for most patients in your experience?

Bill Salt, M.D.: We take the position that the most important aspects of treatment include helping patients understand that, 1) their symptoms are real and not imagined, 2) science is revealing the reality of alterations and disturbances in the brain/body connection to account for them, 3) there can be a cognitive belief and spiritual dimension to health, coping and healing, 4) self-care – including exercise and healthy diet – are very important, and 5) there are medications that may be helpful in the management of predominant symptoms. You emphasize a mind-body-spirit approach to treatment. Please explain this approach a little and describe how its benefits exceed those of traditional medicine alone.

Bill Salt, M.D.: The last century has brought remarkable advances in biomedical technology and treatment. As a society, we have come to expect that effective treatments and cure should be available for many to most medical conditions. Yet, most of the symptoms, syndromes, and illnesses that people experience cannot be explained by organic disease identifiable by currently available medical tests and the biomedical model of illness, disease, healing, and health.

Most of these medically unexplained “functional” symptoms and illnesses are related to medical labeling (medicalization) of functional symptoms as functional syndromes (e.g., fibromyalgia and irritable bowel syndrome), stress and the stress response, the emotional brain and emotional distress, negative thinking and beliefs, and unhealthy lifestyle choices and behaviors. These factors also cause or contribute to serious diseases, such as insulin resistance syndrome (metabolic syndrome X).

The mind, brain and body, and gut cannot be separated. There is a scientific and neurobiologic basis of this Mind/Brain-Body Connection that is common to all healing traditions. Understanding homeostasis (internal stability), the stress response, the emotional brain, distinctions between treatment, cure, and healing, the placebo response, and our innate capacity for self-healing represents the intersection and convergent common ground of ancient, traditional, complementary, alternative, and Western biomedical approaches to health, disease, illness, and healing.

Finally, empiric and scientific evidence continues to confirm that there is a spiritual dimension to the Mind/BrainBody Connection and that spirituality can be beneficial to health. In this regard, an inclusive term is the Mind/BrainBodySpirit Connection and MindBodySpirit medicine. During the holiday season stress becomes a big problem for many people – and for FM and CFS patients, stress can mean triggering a flare up of their symptoms and a subsequent setback in healing. What is your advice for managing stress when you are living with a chronic illness like FM and/or CFS?

Bill Salt, M.D.: Every one of us – doctors included! – must have a self-care plan. There are many paths to coping and healing, but our suggestions include,

• Learn all that you can about the Mind/BrainBodySpirit Connection.

• Accept that emotional feelings, such as anxiety, depression, and negative thoughts can be triggered through the stress response and that they can aggravate and worsen your symptoms. Medical treatment is available, but you should know your options.

• Reduce your allostatic load (bad stress response) through the consistent application of:

– various relaxation techniques, such as breathing exercises, progressive relaxation, meditation, yoga and hypnosis

– positive thinking and recognition of the harmful effects of negative thinking (cognitive behavioral techniques)

– endurance (aerobic) exercise and stretching

– healthy eating (it is usually more important to focus upon overall healthy eating than upon avoidance of suspected food and dietary triggers)

– achieving and maintaining a healthy weight

– obtaining adequate and restorative sleep

– avoiding unhealthy behaviors, such as smoking, heavy alcohol consumption, high demand/low control stressors, and social isolation

• In order that you can work efficiently and effectively with doctors and other health professionals, learn about medical treatment options that may be helpful. What natural approaches for managing FM do you feel are most effective?

Bill Salt, M.D.: Developing a self-care plan, which includes cognitive – behavioral therapy (positive thinking and understanding what fibromyalgia is and is not), exercise, healthy eating, and stress management. What do you think of the newer pain drugs for FM – such as Ultracet and Milnacipran?

Bill Salt, M.D.: Rather than focus upon specific drugs, we prefer to underscore the fact that scientists and physicians are working very hard to develop medicines that help to relieve symptoms of functional disorders, such as fibromyalgia and irritable bowel syndrome. But remember to respect the symptoms. All healing traditions teach that symptoms mean we are out of balance.

I (Dr. Salt) experience all of the symptoms of fibromyalgia during periods of high stress, most commonly when “on call” at the hospital with an 80 to 90 hour work week and much sleep interruption by phone calls and emergencies. I work very hard on self-care to reduce the harmful effects of the stress response. Symptoms can also reflect other imbalances: emotional distress – including depression and repressed anger, and spiritual and existential issues – such as questions about life meaning and purpose. Life is a journey, and symptoms are guideposts. Self-care for FM patients is crucial in the successful management of the disease. If you had to choose one single piece of advice to give FM patients along these lines, what would it be?

Bill Salt, M.D.: Regular endurance exercise.

Final Comment:

The concept that functional symptoms and syndromes – such as fibromyalgia and irritable bowel syndrome – are linked to stress and emotion, does not imply that there is nothing wrong and the problem is imagined or “all in the head.” The symptoms and suffering reflect real illness and can be associated with significant impairment of life functioning and even disability. While emotional feelings and distress – such as anxiety and depression – may be generated through the same Mind/BrainBody Connection dysfunction, can contribute to the symptom experience and illness, and can require treatment, the fundamental problem is not psychiatric and is “not all in the head.”

The book “Fibromyalgia and the MindBodySpirit Connection,” by William B. Salt II, MD and Edwin H. Season, MD can be obtained by calling (614) 445-4949. It is also available in bookstores and on the Internet at,, and

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