Comprehensive Treatment of Fibromyalgia

Comprehensive
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
Common Tender Points
 Midpoint upper trapezius 84-

84-90%
 Medial fat pad of knee 74-
74-90%
 Distal lateral epicondyle 62-
62-86%
 Upper gluteal - iliac crest 60-
60-65%
 Mid SCM 46-
46-65%
 2nd costochondral junction 32-
32-42%
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
 Hormone profile – salivary, serum, or urine

 DHEA, Cortisol, Pregnenalone
 Progesterone, Estrogen
 Comprehensive Digestive Stool Analysis

 Cervical MRI – disc bulge may be present
 Liver detoxification pathway evaluation
DDX:Myofascial Pain Syndrome

 Most common misdiagnosis
 Sleep disturbance – three to four hours
 Typically have five to eight tender points
 Myofascial pain more easily treated
 FMS patients all have myofascial pain
 MPS patients do not have Fibromyalgia
 May progress to FMS if left untreated
5
DDX: Chronic Fatigue
 Chronic fatigue – Epstein Barr connection
 Fatigue dominant symptom
 Cognitive problems
 Non-
Non-exudative pharyngitis
 Swollen lymph nodes
 Low grade fever
 Substance P not elevated
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
DDX: Sleep Apnea

 If a patient has untreated sleep apnea the
sleep disturbance will create a stress
response which can lead to Fibromyalgia
symptoms
 Fatigue will be created by sleep
deprivation
 Lack of growth hormone that should be
produced during deep sleep will lead to
body pain
7
DDX:
Inflammatory Muscle Disease
 Muscle weakness
 Elevated sed rate
 Elevated muscle enzymes
 Enzymes, sed rate are normal in FMS
DDX: Lyme Disease

 Red, hot, swollen joints
 Rash
 Neurological problems
 Bull’
Bull’s eye rash – 60%
 Antibody tests variable
 Doxycycline reduces symptoms
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
 Onset age 50+ years
 SED RATE greater than 50 mm/hr
 RISK – temporal arteritis
 Treatment: steroids
9
DDX: Rheumatoid Arthritis
Lupus
Systemic Sclerosis
 Fatigue and myalgia occur before articular

symptoms
 RA factor, sed rate, ANA titer
 Normal in FMS
 Abnormal in RA, lupus, systemic sclerosis
DDX:
Silicone Breast Implant Reaction
 History of breast implants – even saline
 Dry eyes and mouth
 70% have positive ANA
 Painful joints
 Symptoms can persist even after removal
10
DDX: Tendinitis
 Major areas of tenderness where

muscles attach to the bone
 Rarely in all four quadrants
 History of overuse
 Other Fibromyalgia symptoms missing
DDX: Candida
 Systemic and intestinal candida

symptoms are similar to FMS
 FMS patients may also have
candidiasis
 Historical clues :
 prolonged or frequent antibiotic use
 Frequent vaginal or other yeast infections
 Sugar or fruit cravings
11
FMS is a distinct syndrome
Not secondary to:
 Blood Disease
 Cancer
 Infection
 Hormonal disturbances
 Drug reactions
 Allergies
Onset
 55% Gradual adult onset
 55% could not recall precipitating event
 24% onset after trauma - MVA, surgeries
 14% psychological factors - “stress”

stress”
 Average age of onset - 29-
29-37 years old
 Average age of presentation - 34-

34-53 years
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
 Symptoms persist to some degree

 Articular disability doesn’
doesn’t occur
 Profound fatigue
 Stiffness, paresthesias, muscle tension
 Remission and exacerbation common
 Sleep disturbance can cause relapse
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
A= Normal Delta Wave B= FMS

C= Normal patients roused by sound
14
Reduced levels of:
 Neurotransmitters
 Epinephrine, norepinephrine
 Serotonin
 Dopamine
 Branch chain amino acids

 Tryptophane
 Tyrosine
 Leucine
 Isoleucine
Muscle Fiber Changes

 Moth eaten type 1 muscle fibers
 Ragged red fibers
 Swollen mitochondria
 Atrophy of type II fibers
 Glycogen deposits in muscle cells
 Mucopolysaccharide deposits
 Non-
Non-specific inconsistent changes
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
 Serotonin, MHPG, Dopamine
 Central pain processing abnormal
 Pain perception is linear
 Animals show this pattern in

 central sensitization
 reduced dorsal horn threshold
18
CNS Disorder
 SPECT Scans show decreased blood
flow to caudate nucleus & thalamus
 Decreased flow to prefrontal area in
depression
19
Neuroendocrine Disorder
 Loss of diurnal cortisol fluctuation
 ACTH response to CRH elevated

 In depression – ACTH response is normal
20
21
Hormonal Perturbations in Fibromyalgia Syndrome
Annals New York Academy of Sciences, Neeck & Reidel
Simultaneous injections of CRH, TRH, GHRH, LHRH
 Fibromyalgia patients differed from Controls

 CRH, AVP elevated in chronic stress
 AVP increases ACTH release
 AVP sustains the HPA axis in chronic stress
 CRH increases somatostatin

Injections of CRH, TRH, GHRH, LHRH
 GH and TSH decline in stress

 Mediated by somatostatin
 CRH elevates Somatostatin suppresses GH

 Somatomedin C / IGF-
IGF-1 reduced in FM
 GH reduced due to loss of delta sleep
 GH reduced by low thyroid or elevated
corticosteroids
22
 Fibromyalgia response to TRH

 Blunted TSH secretion
 Somatostatin inhibits pituitary thyrotrophs (TSH)
 Higher prolactin secretion
 Lactotrophs not effected by somatostatin
 Free T3 and free T4 diminished
 Low levels of free T3
 Failure of deiodination of T4 to T3
Thyroid Stress Response
 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
CRH stimulation response
 ACTH increased in Fibromyalgia
 Cortisol release blunted

 Adrenal depletion, secondary adrenal atrophy
 Down-
Down-regulation of ACTH receptors
25
Burkhardt, Clark, Bennett, J. of Rheum. 1993
CRH Stimulation test
Burkhardt, Clark, Bennett, J. of Rheum 1993

ACTH response – Insulin induced hypoglycemia
26
CRH inhibits LHRH directly
Reduces gonadal hormones
GHRH effect on GH
27
Parathyroid Hormone, Calcitonin, and Calcium
 Pain may be caused by metabolites

 released from energy-
energy-depleted muscles
 could stimulate nociceptive nerve fibers
 Classic symptoms of hypocalcemia:
 Muscular pain and stiffness
 Dermographism
 Cold hands and feet
 Paresthesias
 General excitability of peripheral nerves

 Electromyography in FM showed latent muscle tetany
 Lower levels of total and free calcium in FM

 Parathyroid hormone levels no different
 Calcitonin not measurable or at detection levels
 Reduced calcium intestinal uptake
 Increased urinary excretion of Calcium
caused by increased glucocorticoid levels
28
Parathyroid Hormone, Calcitonin, and Calcium

 Hypothyroid FM patients treated with Thyroid
 Restored plasma calcium
 Raised parathyroid hormone
 Combined disturbance of HPA and HPT seem

to affect calcium metabolism in FM patients

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
 Animal studies: early stress alters the HPA axis

response to stress when animals mature
 Animal studies show chronic stress in adults
increases HPA response to novel stimuli
 Increased ACTH response
 Increased cortisol levels
 Patients who develop FMS, CFS may have
underlying vulnerability linked to CNS/NES
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
 Increased UC excretion in PTSD and

major depression patients
 24 hour-
hour-UC same in fibromyalgia and
normal controls
 No correlation between Hamilton
depression scale score and UC
 No correlation between myalgia and UC
30
Fibromyalgia and Cortisol
 Increased urinary excretion
 Normal morning peak; Elevated evening trough

 Diverts tryptophane from serotonin
 Loss of normal diurnal cortisol fluctuation
 Elevated serum cortisol levels – 1 study

 Cannot be suppressed by dexamethazone
Depression and Cortisol

 Elevated serum cortisol
 Increased CRH
 Decreased response of ACTH to CRH
 ACTH response to CRH exaggerated in FM
 Diurnal rhythm altered

 Earlier morning surge
 Increased afternoon surge
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
 FMS symptoms similar to steroid withdrawal.

 30% reduction in ACTH and epinephrine response to
hypoglycemia
 Reduced Neuropeptide Y in FM
 Impaired ability to activate the HPA axis and
sympathoadrenal system
 “Those with the poorest health (FIQ)had the greatest
reduction in sympathoadrenal function”
function”
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, Testosterone, IGF-

IGF-1, Serotonin,
 Fibromyalgia Impact Questionnaire (FIQ)
 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
Therapeutic Strategies from Dessein
 Aerobic exercise stimulates

 HPA axis function
 Cortisol
 Anabolic androgenic axis function
 Growth hormone
 Serotonin production
 Relaxation techniques improve

androgen and serotonin metabolism
33
 Amitriptyline promotes stage 4 sleep

 Long term use of Tricyclic agents is
associated with suppression of HPA
axis function
 Only low doses tolerated by FMS
patients
 Explains loss of efficacy over time
 Obesity and insulin resistance associated

with decreased HPA axis activity
 Obesity associated with impaired serotonin

metabolism and growth hormone production
 Weight loss improves growth hormone

levels
34
Prescription Therapeutics
 Amitryptoline - Elavil
 SSRI’
SSRI’s - Paxil and Trazadone
 Ibuprofen and Xanax
 Hypnotics: Halcion, Restoril, Ambien
 Clomipramine
 Cyclobenzaprine (Flexaril) - & Ibuprofen
Oxytocin and DHEA

• DHEA reduced in FMS
• Oxytocin activates cyclic AMP in cell membranes
• DHEA levels measured
• DHEA & Oxytocin supplemented as needed
• 66% positive response (Stodinger)
• Side effects – water retention, weight gain
35
Guaifenesin: St.Amand, UCLA
 300 to 600 mg, BID = Rx dose

 200 mg capsules = OTC dose
 Cycles of symptom flare-

flare-up
 Regular cycles of “good”
good” and “bad”
bad” days
 Until “good days”
days” predominate
 Avoid salycilates, herbs
 Guaifenesin = NMDA inhibitor
 Increases descending pain inhibition
Cytomel – T3
Lowe, John DC, Journal of Myofascial Therapy, Vol1, July 1994
Improvement in Euthyroid Fibromyalgia Patients treated with T3
 T3 is the active form of thyroid hormone

 Hypothesis that receptors are resistant
 Increased Cortisol
 Decreases TSH
 Shifts from beta to alpha adrenergic
receptors
 Supraphysiologic doses 150-
150-250 mcg
 No stimulation side effects
36
Appropriate Pain Management
 Narcotics may be necessary

 Opiods safer than Tylenol or chronic
NSAID’
NSAID’s
 Once pain is reduced narcotic withdrawal
can be managed appropriately
 Addiction/dependence can complicate
recovery and motivation
Drugs That Don’t Work

 Zopiclone
 Fluoxetine (Prozac)
 Chlormezanone (Trancopal)
 Benzodiazapines - Valium
(Contraindicated)
 Imipramine (Tofranil)
 Steroids are contraindicated

 Except for small replacement doses in CFIDS
37
Non-Prescription
Therapeutics
Magnesium and Malic Acid

Flechas, A Journal of Nutritional Medicine, (1992) 3, 49-
49-59
 1200 - 2400 mg Malate

 300 – 600 mg Magnesium
 Reduces myalgia
 Best for reducing myofascial pain
38
Detoxification: 4 R program
 Theory: toxicity, oxidative stress, immune

system upregulation, intestinal dysbiosis,
increased gut permeability causes
 Dysfunctional oxidative phosphorylation
 Remove: allergic foods, toxicity, infection
 Replace: anti-
anti-oxidants, amino acids, fiber
 Re-
Re-inoculate: friendly gut bacteria
 Repair: gut, liver de-
de-tox pathways
5 - Hydroxy - Tryptophane
Puttini, PS, Fibromyalgia syndrome and 5HTP,
Journal of International Medical Research, April 1992.
 5-HTP 100mg TID, 90 day trial, 50 patients

 Improved: p= .001
 Decreased subjective pain
 Morning stiffness
 Anxiety, fatigue
 Sleep quality
 No one removed from study for side effects
39
5 - Hydroxy - Tryptophane
Nicolodi, M. “Fibromyalgia and Migraine”
Migraine”,
Adv Exp Med Biology 1996
 Fibromyalgia and migraines

 5-HTP, 400mg /day
 As effective as Tricyclic Antidepressants or
MAO inhibitors
 No one removed from study for side effects
Serotonin Metabolism
 Reduced serotonin associated with

 sleep disturbance and
 increased pain perception
 1% of serotonin becomes melatonin

 Stimulates growth hormone
 Promotes deep sleep, somatomedin-
somatomedin-C, DHEA
40
Serotonin Facts
 95% of the serotonin in the body is in the

gut enterochromafin cells
 Platelets contain serotonin in
1000 to 1 concentration
 Serotonin increases platelet aggregation
 Ask patients if they bruise easily
41
Tryptophane Facts
 Tryptophane is least common amino acid-

acid- 1%
 Spirulina seaweed
 Soy nuts
 Pumpkin seeds
 Turkey
 Chicken
 Tofu
 Almonds
Tryptophane Metabolism
Absorbed tryptophane
 90% protein synthesis
 9% niacin production
 1 to 10% converted to 5-
5-HTP and serotonin
42
Tryptophane Conversion
 Tryptophane pyrolase is increased by cortisol
 Converts tryptophane to
 Kynurenine
 Picolinic acid
 Niacin
Electro-acupuncture: 2 studies
1. 75% of patients improved vs. sham
2. 46% of patients said electro-

electro-
acupuncture gave them the best relief
of any therapy
43
Aerobic exercise: inconclusive
 Helps some patients
 Warm water swimming is best
 Makes the most impaired patients worse

 Anaerobic threshold
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
N=40 12 week treatment, 24 week follow-

follow-up
More effective than physical therapy
Decreased pain
Decreased fatigue on awakening
Improved sleep pattern
Improved global assessment
Every patient is hypnotized

Every patient who is
 Focused on eye contact, touch or pain
 Laying face down on a treatment table
 Sensory deprived – mentally focused
Is automatically in a state of hypnosis
 Use language carefully
 Build images deliberately
45
Imagery, Progressive Muscle Relaxation
Walco, Ilowite, Journal of Rheumatology Jan, 1991
 Juvenile Fibromyalgia (N=7)
 Reduced pain
 Improved functioning
Advice for Patients

 Take it Easy
 Simplify your lifestyle
 Pace yourself
 Take time to meet your own needs
 Use your time to do rewarding things
 Be persistent, positive and determined
 Accept the diagnosis
 Reject the verdict
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
 Fibromyalgia can be disabling

 Disability litigation complicates treatment
 Patient has to decide which to do
 Can do one or the other
 Can do one and then the other
 Leave it up to the patient
The Trouble with Fibromyalgia

 The research can be confusing
 Cortisol, ACTH
 Thyroid
 Therapeutic response can be variable

 Nothing works in everyone
 The patients are complex
 What is primary?
 What is compensatory?
 What do you fix first?
48
It is easier if you recognize
Different Types of Fibromyalgia

 Cervical Trauma
 Toxicity Based
 Stress Based
 IgG food sensitivities
 Peri-
Peri-menopause and myofascial pain
 Genetic Type
 Immunologic Type
 Vestibular Injury / Sleep deprivation
 Some combination of two types
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
Treatment Protocols For
Fibromyalgia
50
The most important thing you need
to know about Fibromyalgia is that
it is curable.
Not in every patient

or in every case
But, it is curable often enough that

a cure should be the intended goal
of therapy.
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
 Sympathetic and adrenal upregulation – Elevates

CRF – CRH, Cortisol
 ↑ Cortisol leads to thinning of the gut wall
 Leaky gut → food allergies (IgE
(IgE),
), sensitivities (IgG
(IgG))
 Cortisol reduces ↓T4 /T3 conversion
 Increases T3 to RT3 conversion?
 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”
 Alterations in cognitive function – CRF acts as

neurotransmitter
 Impaired processing and short term memory
 Selective long term memory
 Central pain amplification

 Thalamus changes from pain suppression to pain amplification
53
 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
 Alterations in immune system functions

 No bacterial illness but allergic to everything
Microcurrent treatment of Fibromyalgia

associated with
cervical spine trauma
JBMT, July 2005, 9 169-
169-176
Carolyn McMakin, Walter Gregory, Terry Phillips
Background
 Fibromyalgia is 13.3 times more common following
cervical injuries
 24% of fibromyalgia patients report onset after
cervical trauma
 2 million patients have fibromyalgia from cervical
trauma (CTF)
54
Typical Symptoms
 Neck and midscapular pain

 Shoulder, arm, hand
 Back, leg, foot pain
 Starts in neck
Generalizes in one to three months
 VAS 7.3 ± 1.2 (range 5-

5-10/10)
 Resistant to narcotics
 Aching, burning, tingling, stabbing
 Characteristic affective response
Neurologic Examination
 Hyperesthesia usually at C3, C4, C5

 Patellar reflex +3/4
 Upper reflexes +2/4
 Differs from fibromyalgia
not related to trauma
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
 Chronicity avg 9.5yrs (1-

(1-50 years)
 Blood sample data on subset of six patients
 Did not differ in age or chronicity
 Control patient myofascial pain from trigger points
CTF Treatment Protocol

 Only one frequency protocol
reduces pain – 40 hz,
hz, 10hz
 Trial and error
 Polarized + current
 P = 7.4 to 1.3/10 in 90 min
 Lasts 1 hour to two weeks
 Recovery program is
individualized
 FSM in office, FSM home unit
 Physical therapy, reconditioning
 Supplements
56
IL-1 normal= 0-
0-25pg/ml
392.8
400
Reduced from average 350

300
330 ± 39 to 80 ± 31pg/ml 250

200
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
305 ± 36 to 78 ± 35 pg/ml 150
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
#1 CGRP = 100.8 120

40/10
100
#2 CGRP = 97.6
80
40/390
60
#3 CGRP = 61.3
40, 120/ discs, C5 40
#4 CGRP = 22.4 20
970/ series 0
10:50 11:20 11:35 12N 12:35
#5 CGRP = 8.6
Beta Endorphin normal 0-

0-35 pg/ml
88.3
90
80
70
Increased from average 60
50
8.2 ± 2.5 to 71.1 ± 9.3 pg/ml 40
30
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
neuropeptide –y goes down

Follows endorphins
20
18
16
Neuropeptide - Y
14
12
10
8
6
4
2
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
Cervical Myofascial Pain

50 Cases published – TICC, 1998
 4.7 yrs avg chronicity
 Range: 1 to 28 years
 88% failed with other
treatments
 11.2 treatments
 7.9 weeks
 Start VAS 6.8/10
 End VAS 1.5/10
61
Lumbar Myofascial Pain
23 Cases Published - JBMT, 2004
 8.4 years avg chronicity:

 Range: .1 to 20 yrs
 87% failed with other
treatments
 5.7 treatments
 5.7 weeks
 Start VAS 6.8/10
 End VAS 1.6/10
Results
 VAS before treatment 7.3 ± 1.2 (range 5-5-10/10)
 VAS after treatment 1.3 ± 1.1 (range 0-

0-4/10)
 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
 Films often read as normal
 X-rays may show retrolisthesis

 Flexion-
Flexion-extension films may show
increased translation
Cervical Trauma Fibromyalgia Hypothesis

 Trauma cracks the disc annulus
 Nucleus pulposus is high in PLA2
 Both the nucleus and PLA2 are neurotoxic
 Concentration dependent damage
 Anterolateral tracts are directly adjacent
to disc damage
 Cord is exposed to the nucleus and PLA2
 Either directly or through the vasculature
 PLA2 creates a chemical lesion
 Reduces conductivity in anterolateral tracts
 Creates centrally mediated or thalamic pain
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
This model explains:

 The symptoms
 The persistence of symptoms
 The physical examination findings
 The neurological examination findings
 The persistence of pain even after
discectomy and fusion
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
 Pain generalizes in one to three months
 Characteristic of deafferentation injuries
Neuropathic Pain Causes:

 Sympathetic and adrenal upregulation
 Thinning of the the gut wall
 Alterations in digestive function
 Alterations in liver detoxification functions
 Alterations in immune system functions
 Alterations in microcirculation
66
Treating Cervical Fibromyalgia
 First patient success February 1999
 Trial and error
 Desperation
 Immediate response to treatment after
two months of ineffective treatment
Typical CTF Patient

 AK: 49 year old female
 18 years chronicity , MVA onset
 Headaches, burning mid-
mid-scapular pain, hand,
hand,
arm, leg, foot,
foot, neck and back pain, jaw pain
 Other S/S: asthma, allergies, acne, IBS
 Pain varied 4/10 to 8/10
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
Optimal CTF Response

 12 / 8 : 14 of 18 tender points
 Cervical ROM improved by 40%
 Pain medication reduced by 95%
 Muscle relaxants reduced by 95%
 Sleeping well, medication eliminated
 Acne clearing up - Vitamin A
 Digestion improved/ IBS resolved
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
 Wrap black leads glove in a wet towel and

 Wrap around the feet or put adhesive conductive
pads on the soles of the feet.
Cover the patient with a blanket

The towels cool off quickly
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
 Sometimes you need to remove “trauma”

trauma” first
 Use 94/10 for 30 to 60 seconds when the
response seems slow to 40, 284/10
Increasing Range of Motion

“Chronic inflammation leads to
hardening and fibrosis”
fibrosis”
 Fibrosis from the chronic inflammation in
the cord and nerves causes restriction and
increased pain with motion
 As patients start to feel better and increase
their activities, they may experience an
increase in deep aching pain or a burning
pain especially in the arms, legs and feet.
72
Treating CTF – Cord Fibrosis
91, 13, 3 / 10 + →
Once the pain is down to 0- 2 / 10, have the patient sit up

With leads at the neck and feet - Treat for adhesions in the cord
Have the patient bend forward until to the edge of pain or stiffness
Continue treating and go back to Neutral
Treat for 60 seconds – Polarized + current
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
 Use HOME UNIT – P / CTF

 As needed to keep pain at or below 4/10
 6 to 18 hours /day
 Make sure the patient stays hydrated
Resonance for Central Amplification

 40 / 89 +→
+→
 Central pain amplification
 Thalamus resets pain threshold and changes function
from pain suppression to pain amplification.
 When you treat a patient with the 40,284 / 10
protocols they experience an incongruence
reaction after their pain goes down.
 They describe feeling as if they should still be in
pain even though they are not and the pain-
pain-free
state feels strange.
74
Address The Central Component
 40 / 89, 90, 84, 94
 Polarized neck to feet
 970 / 89, 90, 94, 84?
 Address the entire pain processing system
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
 40 / 562 quiets it down Neuropeptide Y

20
Pay attention to body

18
 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
Summary Protocol For

Fibromyalgia Associated with Cervical Trauma
 Apply neck to feet
 Prep tissue with 40, 50 / 10 alternating (+/-)
 40, 284, 91, 13, 3, 81, 49 / 10 +>>>
 Polarize the current positive
 Move the cord during 3, 13 / 10
 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
 Pain level will be 7-

7-9/10 – intolerable
 Unresponsive to narcotics
 The pain diagram and descriptors are similar
to the 40, 284 / 10 patients but the 40, 284 /
10 protocol doesn’
doesn’t work.
Resonance For Central Pain
 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
Medication Management and Withdrawal

Narcotics, Antidepressants
 Once the pain is down they are automatically
overmedicated
 Meds that were well tolerated now cause side effects
 May blame FSM or treatment
 Work with prescriber and patient to reduce dose
 Gradual withdrawal is less problematic
 Do pain meds first, psych meds last
 Addiction issues show up
 Narcotic withdrawal is not always smooth
 Home Care helps
 Side effects become more apparent
 Flat affect, loss of libido, anxiety
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
 Emotional and Psychological 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
 Energy should start coming up in about 2

to 4 weeks
 Takes about 2-
2-4 months depending
 Can take up to 6-
6-12 months to complete
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
 Allergy testing – IgG

 Elimination Diet
 Usually takes 1-
1-2 months
Orthopedic Issues
 Once the fibro is gone – 4-6 weeks
 The patient still has orthopedic complaints
 Facet syndrome
 Disc bulges
 Ligament instability
 Myofascial pain
 COMPLICATED by central pain upregulation

 They MIND the pain more until 40/10, 89
helps
81
Treat for Specific Orthopedic Issue
Facet Syndrome
 FSM for facets
 40, 284 / 59, 39, 783, 480, 157
 91 / 783, 480, 191, 396, 142
 Flexion – traction – exercises

 Avoid extension
 Exercise and Posture
 Supplements
 Glucosamine, Chondroitin, Anti inflammatory

Disc Bulges
 Use FSM for discs and nerves
 40, 284, 49 / 330, 630, 710, 396
 Traction
 Some controversy
 Exercises
 McKenzie Exercises
 Spinal stabilization
 Manipulation
 Injections as needed
 Supplements
82
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

Myofascial Pain – Trigger Points
 Caused or exacerbated by facets, discs,
instability, stress of fibro
 FSM for myofascial pain
 58/’
58/’s● 91,13, 40 / 62, 142, 396
 Massage
 Supplements
 Magnesium, Malic acid
 CAREFUL exercise Rehab
 2 reps into the burn
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.
Emotional Psychological Issues

 Be fully involved in the process
 Do not get attached to the outcome
 Hold the vision of the patient as healed
 Let them share and take responsibility
 End of codependence as we know it
84
I didn’t say it was easy or simple
I said it was possible
Treating Other Types of Fibro

 Prolonged Stress
 Food Allergies
 Toxicity
 Immune System / Viral
 Progesterone Deficient
 Vestibular Injury
 Sleep Apnea
 Genetic
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
 MUST do salivary hormone testing first

 No test is as expensive as the time and money
wasted on ineffective or misdirected treatment
 Rehab those systems and the fibromyalgia goes
away
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
Evidence that Abnormalities of Central

Neurohormonal Systems are Key to Understanding
Fibromyalgia and Chronic Fatigue Syndrome
Leslie Crofford, MD, Mark Demitrack, MD, 1996
 Animal studies show early stress alters the HPA axis
response to stress when animals mature
 Animal studies show chronic stress in adults
increases HPA response to novel stimuli
 Increased ACTH response
 Increased cortisol levels
 Patients who develop FMS, CFS may have
underlying vulnerability linked to CNS/NES
87
Case : DF
 50 year old woman
 Presented 11/2/98
 Dx: Fibromyalgia 1991
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
 Pain in neck, shoulders and low back

 Pain rated as 10/10 - varying 5 to 10/10
 Fatigue
 Sleep disturbance – sleeps 90 minutes
 Depression
 Irritable bowel
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
IgG Food Allergies

 IgG food and mold allergies
 Form antigen-
antigen-antibody complexes
 Taken up by macrophages
 Macrophages release histamine
 Histamine stimulates class C pain fibers
 Histamine causes both irritability and fatigue
 Pain and fatigue create stress, sleep

disturbance, adrenal changes → Fibro
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
 Serum testing is most reliable

 Electrodermal testing almost too sensitive
 Avoid allergens – 4 -12 weeks
 Repair Gut
 Glutamine, arabinoglycans, fiber, bacteria
 Rotation diet
93
Treatment Protocol
Allergy Connection
 Serum IgE, IgG food allergy testing

 Serum IgE, IgG mold allergy testing
 Hypoallergenic diet
 Environmental control
 Avoidance
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
Toxicity Based Fibromyalgia

Hypothesis
Organic chemical exposure causes:
 Overload in liver detoxification pathways
 Membrane dysfunction
 Class C pain fibers respond to chemicals
 Pain and fatigue cause:
Sympathetic upregulation
Sympathetic sequellae
Gut, liver, adrenals
95
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
Fibromyalgia History Challenges

 Patients think symptoms are random and
just part of the syndrome.
 The concept that symptoms have a cause
related to something in the history is new
to them.
 Once they are sick it is hard to remember
ever having been well.
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.
General History Questions

 What are your current symptoms ?
 When did they start – exactly ?
 What were you doing just prior to the onset ?
 What makes them better ?
 What makes them worse ?
 What have you done that helps ?
 What medications are you taking ?
 Are the symptoms getting better or worse ?
97
Toxicity based Fibromyalgia
History Questions
 Have you ever worked on or near a farm or an orchard ?
 Have you ever worked in or near a chemical factory?
 Did you have any pesticide or chemical exposure just

prior to the onset of your symptoms?
 Where does your drinking water come from ?
 Do other people in your building complain of being ill ?
 How do you respond to massage?
 How do you react to alcohol or Tylenol?
Case: KS
First seen 4-
4-2-99
Dx: Fibromyalgia 1995

 Worked as an office manager
 Sick building
 Married, 3 children
 Hadn’
Hadn’t worked in 4 years
 Eats healthy diet-
diet- juices, fruits, salmon
 Unable to exercise but does stretches
 No smoke, no ETOH
98
KS: Symptoms
 Pain rated 7 - 9/10 since 1992

 Felt like she had the flu constantly
 Fatigue, pain, cognitive symptoms
 Massages make her really sick
 100 degree fevers, 3 per week
 Sleep OK for weeks then no sleep for weeks
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
 Ultram – daily for pain
 Vicodan – occasional for flare-

flare-ups
 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
 LLF 30/40, RLF 40/40
Dx: Fibromyalgia / MPS

Pending labs
 Ordered CBC, Chem screen, Thyroid
panel, blood type (4/3/99)
 Visit 4/7/99 patient remembered that
she worked at Viewmaster
 Well water was contaminated with TCE
 1200 ppm (6 X higher than “Civil Action”
Action”)
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
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
Resonance for Full Body Pain

associated with Chemical Exposure
40, 284, 57, 920, 900 / 45, liver +/-
 Organic chemicals are fat soluble

 Nerve tissue is largely fat.
 Patients chronically exposed to organic chemicals can
end up with full body aching.
 Address the organs of elimination
 Liver, kidneys, the colon and even the lungs for toxicity
and chronic inflammation
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
Progesterone Deficiency “Fibro”

 Peri-
Peri-Menopause and menopause
 Women 40 to 60
 Progesterone drops first
 Estrogen dominance leads to
 Fatigue
 Emotional changes - depression
 Neurological changes – sleep disturbance
 Medications – sleep, pain, depression
 Hysterectomy – further hormone dysregulation
 Myofascial Pain
 Combination => Fibromyalgia
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
Vestibular Injury – “Fibro”

 Vestibular injuries => vision dependent
balance, cognitive dysfunction, sleep
disturbance, neck muscle tightness,
anxiety, PTSD symptoms
 Leads to Fibromyalgia
 Diagnosis most important
 Screening examination
 Laboratory testing confirms diagnosis
 Find a specialist to treat
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
 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”.

 Cognitive function, memory and sequencing
depend on the movement of information from
short term to intermediate and long term
memory
 Vestibular injuries inhibit the movement of
information from short to long term memory
 Patients specifically have trouble with
sequencing, memory for numbers and
names
 Can be mistaken for “fibro fog”
fog”
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?

 Do you have a feeling of fullness in one or
both ears?
 Are any of these symptoms worse when it
rains or when the air pressure changes?
112
 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?
Vestibular Screening Exam

 Weber’
Weber’s, or modified Weber’
Weber’s: Place a 128 or
256 tuning fork on the top of the head or at the
center of the forehead. The patient should hear
the sound equally in both ears. If there is an
inner ear injury the sound will lateralize.
 Air Conduction: If the inner ear is damaged the
sound will be aversive on one or both sides. This
is not a true Rinne’
Rinne’s test. You are just checking
to see if the tuning fork tone is bothersome
 Fields of Gaze: The eyes should track smoothly.
Horizontal gaze return shows nystagmus or
saccadic pursuit
 Modified Rhomberg:
Rhomberg: Heel toe walking with eyes
closed – patient will fall
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
Care with FSM

 If the vestibular tests are strongly positive use
the concussion protocol carefully
 Ask them if they feel OK when you get to 94/94.
 If they tolerate 94/94 they should be fine
 The concussion protocol is very helpful to these
patients if they tolerate 94 / 94, 44
 If they react to 94 / 94
 Use Meclizine
 If willing – repeat treatment until reaction goes away.
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
Sleep Apnea - Fibro

 Sleep Apnea interferes with stage 4 sleep,
creates oxidative stress
 Patients have daytime fatigue, sleep drive
 Develop body pain, cognitive dysfunction,
adrenal fatigue due to sleep deprivation
 Adrenal, GI, neuroendocrine changes
follow
 => Fibro
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
 Everyone is raised in a pesticide use area?

 Everyone has same diet, ie wheat?
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
Treating Genetic Fibro

 Determine what trait is causing the problem
 GI-
GI-food allergies, Serotonin, Liver detox or??
 Support and change that system
 FSM
 Concussion protocol
 Constitutional type 42/00, 48/00, 43/00, 55/00
 Address the system that is most likely problem
 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

Comprehensive Treatment of Fibromyalgia

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Comprehensive

Common Tender Points

 Midpoint upper trapezius 84-

 Hormone profile – salivary, serum, or urine

 Comprehensive Digestive Stool Analysis

DDX:Myofascial Pain Syndrome

 Fatigue dominant symptom

 Swollen lymph nodes

 Low grade fever

 Substance P not elevated

DDX: Sleep Apnea

 Elevated sed rate

 Elevated muscle enzymes

 Enzymes, sed rate are normal in FMS

DDX: Lyme Disease

 Onset age 50+ years

 SED RATE greater than 50 mm/hr

 RISK – temporal arteritis

 Fatigue and myalgia occur before articular

 RA factor, sed rate, ANA titer

 Abnormal in RA, lupus, systemic sclerosis

 History of breast implants – even saline

 Dry eyes and mouth

 70% have positive ANA

 Symptoms can persist even after removal

 Major areas of tenderness where

 Rarely in all four quadrants

 Other Fibromyalgia symptoms missing

 Systemic and intestinal candida

 55% could not recall precipitating event

 24% onset after trauma - MVA, surgeries

 14% psychological factors - “stress”

 Average age of presentation - 34-

 Symptoms persist to some degree

A= Normal Delta Wave B= FMS

 Branch chain amino acids

Muscle Fiber Changes

 Serotonin, MHPG, Dopamine

 Central pain processing abnormal

 Pain perception is linear

 Animals show this pattern in

 reduced dorsal horn threshold

 SPECT Scans show decreased blood

flow to caudate nucleus & thalamus

 Decreased flow to prefrontal area in

 Loss of diurnal cortisol fluctuation

 ACTH response to CRH elevated

Simultaneous injections of CRH, TRH, GHRH, LHRH

 Fibromyalgia patients differed from Controls

 CRH increases somatostatin

Hormonal Perturbations in Fibromyalgia Syndrome

 GH and TSH decline in stress

 CRH elevates Somatostatin suppresses GH

 Fibromyalgia response to TRH

Thyroid Stress Response

CRH stimulation response

 ACTH increased in Fibromyalgia

 Cortisol release blunted

Burkhardt, Clark, Bennett, J. of Rheum 1993

 Pain may be caused by metabolites

 Cold hands and feet

 General excitability of peripheral nerves

Hormonal Perturbations in Fibromyalgia Syndrome

 Electromyography in FM showed latent muscle tetany