by Daniel J. Murphy, DC, FACO

 

  

             Fibromyalgia Syndrome is the third most commonly diagnosed rheumatologic disorder, following osteoarthritis and rheumatoid arthritis. Fibromyalgia is characterized by widespread pain and tenderness, fatigue, morning stiffness, and sleep disturbance. Fibromyalgia is often disabling. Fibromyalgia is often treatment resistant. Fibromyalgia can be triggered by trauma (Greenfield, Waylonis, Buskila, Neumann). Studies report that between 25% and 50% of subjects with fibromyalgia recall physical trauma immediately prior to the onset of their symptoms (Al-Allaf).

            Chiropractors usually manage patients with fibromyalgia by attempting to enhance the quality of mechanical neurological afferentation by improving the sagittal and horizontal planes of spinal posture and motion. However, these efforts will often worsen patient symptoms, at least temporarily.

            This article reviews several adjunct approaches to the management of patients with fibromyalgia syndrome.

 

MALIC ACID and MAGNESIUM

            In 1992, Abraham and Flechas proposed that fibromyalgia is caused by a deficiency of substances needed for ATP synthesis. The nociceptive nervous system requires a steady flow of ATP to remain subthreshold. Therefore, reductions in ATP supplies could account for the lowered pain thresholds that fibromyalgia patients experience.

            Abraham and Flechas explain the synergistic role of magnesium and malic acid in the genesis of ATP. They detail the biochemistry of how reductions in magnesium and malic acid would result in ATP deficiency.

            Abraham and Flechas then treat 15 fibromyalgia patients with daily 300-600 mg of magnesium plus 1200-2400 mg malic acid. “All patients reported significant subjective

improvement of pain within 48 hours of starting” supplementation.

            In 1995, Russell et al in a randomized, double blind, placebo controlled, crossover study, also used magnesium and malic acid to treat 29 patients with fibromyalgia, noting

“significant reductions in the severity of all 3 primary pain/tenderness measures were observed.” Better results were observed in those taking 600 mg of magnesium and 2400 mg of malic acid, as compared to those who took lower doses. The authors note that this supplementation should continue for at least 2 months.

 

THE SEROTONIN PATHWAY

            In 1998, osteopath John H Juhl proposed that fibromyalgia could be related to reduced serotonin. He notes that researchers have found low serum levels of serotonin in fibromyalgia patients. Low serum serotonin levels have been found to have an inverse correlation with clinical measures of pain.

            The serotonin pathway begins with the essential amino acid tryptophan.Tryptophan is the least common of the 8 essential amino acids, accounting for about 1% of protein content.

            After absorption, about 90% of tryptophan is used at the peripheral tissues for protein synthesis.

            About 9% of absorbed tryptophan is used to produce niacin. The RDA for niacin is 15 mg. It takes 60 mg of tryptophan to produce 1 mg of niacin. This is important, because if niacin levels are adequate in the diet, the body will not need to use this 9% to make niacin. In fact, the higher the dietary levels of niacin, the less tryptophan is converted to this pathway. This increases the tryptophan available to be converted to serotonin.

            About 1% of absorbed tryptophan is converted to serotonin.

            In the body, tryptophan is converted to 5-hydroxy-tryptophan (5-HPT). 5-HTP easily crosses the blood-brain barrier for conversion to serotonin in the central nervous system. The conversion of 5-HPT to serotonin requires vitamin B6. Consequently, inadequate levels of B6 impair the conversion of tryptophan to serotonin.

            Currently, tryptophan is available by prescription only in the United States. However, 5-HTP is sold, and as noted above, still crosses the blood brain barrier for conversion to serotonin. Commercially, 5-HTP is extracted from the seeds of Grifonia simplicifolia, a plant grown in West Africa.

            Dr. Juhl notes two published studies where supplementation of 5-HTP in the dose of 100 mg 3 times per day in patients with fibromyalgia resulted in significant improvement of clinical symptoms after 30-90 days.

The effective daily dose range appears to be 200-1000 mg total per day, and that it should be taken with meals. These patients should also be given vitamin B6 to increase conversion of 5-HTP to serotonin, and niacinamide to inhibit the need for tryptophan to convert to niacin.

 

LOW LEVEL LASER THERAPY

            I have reviewed three studies that show significant benefit to management of chronic pain and fibromyalgia using low-level laser therapy. The first article is by Green, et al in 2000. The authors claim excellent positive therapeutic results in treating patients with chronic painful diabetic neuropathy, chronic myofascial pain, or complex regional pain syndrome.

            Green et al conclude, “It appears that photon stimulation carries with it a significant potential for amelioration of chronic pain in which autonomic and neurovascular abnormalities are, in fact, present.”

            The second article is a randomized controlled clinical trial done in 2002 by Gur et al on patients with fibromyalgia. The laser group of patients were treated for 3 minutes at each tender point daily for 2 weeks. The authors note, “Significant improvements were indicated in all clinical parameters in the laser group,” and that “laser therapy can be used as a monotherapy or as a supplementary treatment to other therapeutic procedures in fibromyalgia.”

            The third article is also by Gur and others, published in 2002. It is a single-blinded placebo-controlled trial of low power laser therapy in 40 female patients with fibromyalgia. The authors note that there was a “significant difference was in parameters as pain, muscle spasm, morning stiffness and tender point numbers in favour of laser group.” These authors conclude “Our study suggests that laser therapy is effective on pain, muscle spasm, morning stiffness, and total tender point number in fibromyalgia and suggests that this therapy method is a safe and effective way of treatment in the cases with fibromyalgia.”

            I have four lasers, and I have been using low-level laser therapy since 1988. My best laser is from Erchonia Medical, Mesa, AZ: (480) 633-3129.

 

EXCITOTOXINS

            I have listed five books that deal extensively with dietary excitotoxins and their deleterious effects on human physiology. These deleterious effects include chronic fibromyalgia pain because dietary excitotoxins also function as excitatory neurotransmitters for chronic pain (Dickenson).

            In a nutshell, dietary excitotoxins are added to food because they function as excitatory neurotransmitters, enhancing the flavor of food. The two main dietary excitotoxins are glutamate (often labeled monosodium glutamate or MSG, and aspartame because it is metabolized to the excitotoxin aspartate).

            In excess, these substances can literally excite neurons to death, and therefore have been associated with neurodegenerative diseases such as Alzheimer and Parkinson diseases, as well as a plethora of other symptoms, including fibromyalgia chronic

pain. Unfortunately, excitotoxins such as glutamate can have dozens of names on food labels.

            In 2001, Smith reports on four cases of chronic pain fibromyalgia patients who were successfully treated after avoiding all products that contain the excitotoxins glutamate and aspartame. Some of these patients had suffered for as long as 17 years, and were taking as many as 13 different drugs for their symptoms.

            Smith notes the following:

            “Excitotoxins are molecules, such as MSG and aspartate that act as excitatory neurotransmitters, and can lead to neurotoxicity when used in excess.”

            “MSG, the sodium salt of the amino acid glutamic acid or glutamate, is an additive used to enhance the flavor of certain foods.”

            “MSG, like salt and baking powder, were grandfathered as harmless food substances by the US Food and Drug Administration (FDA) in 1959.”

            “Aspartame was first marketed in 1981, and is a dipeptide of aspartate and phenylalanine used in foods, beverages, and drugs.”

            “In animal models, aspartame has been associated with an increased incidence of brain tumors.”

            “Anecdotally, aspartame use in humans has been linked with headaches, seizures, dizziness, movement disorders, urticaria, angioedema, and anaphylaxis.”

            “Much of the research performed proving that glutamate was safe for human consumption may have been flawed.”

 

            Glutamate has a role in chronic pain sensitization:

   “MSG is nearly ubiquitous in processed food, appearing under many names, including

gelatin, hydrolyzed vegetable protein, textured protein, and yeast extract.”

 

            Aspartame is the dominant artificial sweetener on the market since 1981.

            Fibromyalgia can be caused by exposure to dietary excitotoxins in susceptible individuals.

            Aspartate and glutamate taken together have additive neurotoxic effects.

            The elimination of MSG and other excitotoxins from the diets of patients with fibromyalgia offers a benign treatment option that has the potential for dramatic results in a subset of patients.

 

REFERENCES

            Abraham GE, Flechas JD. Management of Fibromyalgia: Rationale for the Use of Magmesium and Malic Acid. J of Nutritional Med. 1992 (3) 49-59.

            Al-Allaf AW, Dunbar KL, Hallum NS, Nosratzadeh B, Templeton KD and Pullar T. A case-control study examining the role of physical trauma in the onset of fibromyalgia syndrome Rheumatology 2002; 41: 450-453.

            Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rates of fibromyalgia following cervical spine injury. A controlled study of 161 cases of traumatic injury. Arthritis Rheum. 1997 Mar;40(3):446-52.

            Dickenson AH. Gate Control Theory of pain stands the test of time British Journal of Anaesthesia, Vol. 88, No. 6, June 2002, Pgs. 755-757.

            Green J, Fralicker D, Clewell W, Horowitz E, Lucey T, Yannacone V, Haber C. INFRARED PHOTON STIMULATION: A NEW FORM OF CHRONIC PAIN THERAPY. American Journal of Pain Management, Vol. 10, No. 3 July 2000,113-120;

            Greenfield S, Fitzcharles MA, Esdaile JM. Reactive fibromyalgia syndrome.Arthritis Rheum. 1992 Jun;35(6):678-81.

            Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Ataoglu S. Effects of low power laser and low dose amitriptyline therapy on clinical symptoms and quality of life in fibromyalgia: a single-blind, placebo-controlled trial. Rheumatol Int. 2002, Sep; 22(5):188-93.

            Gur A, Karakoc M, Nas K, Cevik R, Sarac J, Demir E. Efficacy of low power laser therapy in fibromyalgia: a single-blind, placebo-controlled trial. Lasers Med Sci. 2002; 17(1):57-61.

            Juhl JH. “Fibromyalgia and the serotonin pathway,” Altern Med Rev 1998;3(5):367-75.

            Neumann L, Zeldets V, Bolotin A, Buskila D. Outcome of posttraumatic fibromyalgia: A 3-year follow-up of 78 cases of cervical spine injuries. Semin Arthritis Rheum. 2003 Apr;32(5):320-5.

            Russell IJ, Michalek JE, Flechas JD, Abraham GE. Treatment of fibromyalgia syndrome with Super Malic: a randomized, double blind, placebo controlled, crossover pilot study. J Rheumatol. 1995 May;22(5):953-8.

            Smith JD, Terpening CM, Schmidt SOF, Gums JG. Relief of Fibromyalgia Symptoms Following Discontinuation of Dietary Excitotoxins The Annals of Pharmacotherapy: Vol. 35, No. 6, pp. 702-706. June 2001

            Waylonis GW, Perkins RH. Post-traumatic fibromyalgia. A long-term follow-up. Am J Phys Med Rehabil. 1994 Nov-Dec;73(6):403-12.

 

Excitotoxin Books

            Excitotoxins, The Taste That Kills by Russell Blaylock (University of Mississippi neurosurgeon), Health Press, 1997

            In Bad Taste, The MSG Symptom Complex, by George Schwartz, Health Press, 1999

            The Crazy Makers, How the Food Industry Is Destroying Our Brains and Harming Our Children, by Carol Simontacchi, Tarcher Putnam, 2000

            Food Allergies by William Walsh, Wiley, 2000

            Health and Nutrition Secrets by Russell Blaylock, Heath press, 2002