纤维肌痛 XIANWEI TONG - FIBROMYALGIA

Fibromyalgia (FM) is nonspecific rheumatism in which typical symptoms are chronic widespread musculoskeletal pain and stiffness with accompanying fatigue, anxiety, sleep disorder; and/or irritable bowel syndrome. Experts in the United States and Canada have developed diagnostic criteria for identifying this disease for the American College of Rheumatology (ACR), which are also commonly used in China. This disease appears to affect increasing numbers of people, with a disabling outcome on their quality of life. As the cause of FM is unknown, it is characterized and diagnosed by its symptoms of chronic widespread pain and multiple tender points associated to some degree of facilitation by the central nervous system. There are two important goals for treating these symptoms. The first goal is reduction of pain, and the second is restoring functionality.

Most cases of fibromyalgia fit into the Traditional Chinese Medicine diagnosis of Liver Qi Stagnation, Spleen Qi Deficiency, or Heart Qi Deficiency; meaning that the functions of those meridians are out of balance.

Fibromyalgia remains an elusive and poorly understood pathology. Evidence in recent years, from John Hopkins Medical Center and others, shows that the exact cause of fibromyalgia still eludes us, but seems to be related to a number of factors, including viral illness, physical or emotional stress, myofascial pain syndromes, autonomic nervous dysfunction, serotonin imbalance, lack of deep sleep, sleep disorder, and low blood pressure. Many of these causative health problems may relate to Adrenal Stress Syndrome, or subclinical adrenal insufficiency, but there is no single type of cause and presentation in fibromyalgia syndrome that can be fit into a neat diagnostic box and treat with a one-size-fits-all protocol.

The fibromyalgia syndrome, which now accounts for about 20 percent of all visits to rheumatologists and affects about 2 percent of Americans, especially women age 40 and over, may be different from one patient to the next, and involve a number of the above causes acting in a cycle of dysfunction. Fibromyalgia is associated with other poorly defined syndromes, including Chronic Fatigue Syndrome (CFS), Guillain Barre Syndrome and various other autoimmune disorders. An estimated one-third of fibromyalgia patients experience restless leg syndrome (RLS) ─a sleep movement disorder that is associated with Rheumatoid Arthritis.

The term fibromyalgia is nonspecific. The name literally means pain (algia) in the muscles (myo) and fibrous soft tissue (fibro), such as the muscle tendon and the connective ligaments, but the disorder may vary considerably from one individual to the next, sometimes affecting the central nervous system more, and sometimes the peripheral nervous system. Like arthritis, or joint (arthro) inflammation (itis), which now has over 44 classified types, fibromyalgia may refer to a variety of presentations of chronic developing myofascial pain syndromes, and include symptoms of neuropathy, anxiety and depression.

Neuropathy may include unpleasant sensations such as numbness and tingling, burning sensation, and heavy or leaden feel to an area of the body (paresthesia and dysesthesia). Often, other syndromes such as IBS and RLS accompany fibromyalgia, and each individual may present with different treatment needs. Any combination of the above factors may be important in the presentation of the syndrome and would need to be addressed in the treatment protocol holistically, even if a pharmaceutical remedy is used. A comprehensive treatment protocol is available in the specialty of Traditional Chinese Medicine with acupuncture, electroacupuncture, herbal nutrient medicine, and patient instruction in improved mind-body cognitive and behavioral habits that will positively impact the recovery. TCM protocols address fibromyalgia with diagnostic pattern differentiation.

In fibromyalgia, or fibromyalgic encephalomyopathy, research has uncovered a number of imbalances, and a number of presentations, with many patients also suffering from other disease mechanisms, especially sleep disorders, anxiety, depressive, and autoimmune disorders. Rarely is fibromyalgic encephalomyopathy a primary disorder, but it is a matter of ascertaining the etiology through interview and other Chinese medicine diagnostic modalities. In Traditional Chinese Medicine the approach is holistic, and thus it is ideal for the treatment of fibromyalgia since what is treated is the pattern or presentation of the illness.  

Researchers at the University of Michigan Medical Center discovered that the same underlying pathophysiology exists for both Fibromyalgia and Chronic Fatigue Syndrome. Dysfunction in the hypothalamus-pituitary-adrenal axis, or main endocrine control in the body, with a moderate basal hypocorticolism, or cortisol deficiency within a diurnal cycle, was a common underlying feature of both of these diseases. Holistic treatment with Chinese medicine include the practice of Qigong and deep meditation, along with other methods, but these two systems alone would address the dysfunction in the hypothalamus-pituitary-adrenal axis.

Traditional Chinese Medicine has historically taken the subject of Mind-Body Medicine very seriously and treats this with a holistic view. The earliest preserved text in TCM, the Huang Di Nei Jing, or canon of corporeal medicine related to Huang Di, stated in the first chapters that TCM physicians observed that emotional constraint was a root cause of most physical diseases, either causing symptoms directly or indirectly, or both. The belief in TCM was that physical disorder caused mental and emotional stress and dysfunction, and likewise, mental and emotional dysfunction caused physical disorder.

These two realms, the Mind and the Body, could not be realistically separated, and treatment must always address both the balance of the mental/emotional health and function, and the physical health and function. Patterns of association between the organ systems and emotional expressions and controls were emphasized by early Chinese Daoist physicians, and continue to be in modern times. The recent emphasis in Mind-Body Medicine in standard medicine has perhaps been prompted by the public interest in Chinese medicine and its success in treating health problems with this approach.      

The Treatment Plan and the Diagnostic Workup in Fibromyalgia

The treatment plan must include a step-by-step approach to the various interwoven health problems combined with changes in the patient’s own routine. This holistic and pro-active patient-centered approach is essential. Standard medicine has no cure, but a comprehensive package of care by the TCM physician, or Licensed Acupuncturist, sometimes integrated with medical doctors that also utilize holistic approaches to care, can have dramatic results. The various therapies of the TCM physician may act synergistically to insure better treatment outcome, combining acupuncture, herbal medicine, nutrient medicine, bioidentical hormone therapy, physiotherapy, nutrition, and patient counseling.

The individual patient will set goals and see progress achieved on any of the factors that make up their pattern. In a short time, after progress is made on a number to the causative factors, and a sequence of herbal formulas and nutritional supplement courses have been completed, the physiotherapies and needling stimulation will be able to reduce the pain and nervous dysfunction. Treatment of both the underlying causative mechanisms and the symptom manifestation will insure the best outcome.

Because fibromyalgia is similar to various autoimmune disorders, such as rheumatoid arthritis, lupus and Sjogren’s syndrome, as well as disorders such as Lyme disease and thyroid dysfunction, various lab tests should be conducted to check for markers such as rheumatoid factor and erythrocyte sedimentation rate (ESR), as well as thyroid and pituitary hormones, and other disease markers.

A diagnosis of exclusion is used, where other diseases are tested for and ruled out. Autoimmune diseases often coexist with fibromyalgia. Negative results of various tests do not rule out the diagnosis of fibromyalgia but do help guide the complex treatment plan. Active metabolite hormonal panels are highly recommended to aid diagnosis, especially to assess cortisol imbalances. These tests are simple to perform, do not require drawing of blood, and are relatively inexpensive and highly accurate.

Patients may collect their own samples of saliva, blood spot, and even urine spot, that are analyzed with advanced scientific methods, providing a useful analysis of overall hormonal balance and thyroid function, key nutritional deficiencies, and metabolic disorders. Even if the disorder is subclinical, meaning that the tested values do not indicate a standard diagnosis of clinical disease, these tests reveal the relative imbalances and holistic dysfunction that need to be brought back into balance to correct the underlying disease mechanisms in fibromyalgia.

Herbal and Nutrient Recommendations

Herbal and nutritional supplements that have been studied and found effective for fibromyalgia include 5HTP from Griffonia seeds, SamE, methionine, magnesium aspartate, chlorella and other algaes, anthocyanadins such as in mangosteen, pomegranate, and other herbs, e.g. gingko biloba. Pomegranate extract from the whole fruit, husk and seeds is recommended. In addition, a variety of herbal formulas, bovine colostrums, proteolytic enzymes, vitamins, amino acids, and immune modulating and adaptogenic herbs may have very positive results and are generally effective in clinical practice.

Hormonal imbalances relating to fibromyalgia

Recent research has uncovered a strong link between the serotonin and estradiol in the brain in relation to chronic systemic pain sensation and modulation. While some studies have shown little obvious relationship to the changing menstrual cycle hormones and the elevated pain threshold, (slightly elevated progesterone levels during the mid-luteal phase, pre-menstrually, in normal subjects with fibromyalgia, pointing to increased need or excess production and fluctuating cortisol concentrations), other studies have shown a definite link to the levels of estradiol hormones and serotonin pain modulation.

Most studies confirm a consistency of deficient central serotonin levels in fibromyalgia patients, which may create a need for increased hormonal regulation of pain at receptors that may be triggered both by serotonin and estradiol, or cortisol. Consistent findings of low androgens and estrogens, serotonin, and growth hormones and growth factors are seen in both fibromyalgia and chronic stress syndromes.

These biochemical deficiencies may need to be addressed to achieve progress with acupuncture, physiotherapy, and bioidentical hormones, bioavailability of serotonin with natural precursors such as 5HTP and L-tryptophan, use of adrenal cortex extract, and other herbal and nutrient strategies allow the Chinese medicine physician, such as the Licensed Acupuncturist and herbalist, to achieve a thorough and holistic approach in the protocol.

The most compelling hormonal link in fibromyalgia research resides in the deficiencies of the hypothalamus and adrenal systems, or the hypothalamus-pituitary-adrenal axis, which is a primary feedback system regulating hormonal balance. When physical and emotional stress creates dysfunction in the adrenal and hypothalamic systems, diurnal cortisol levels are affected, and growth factors become deficient, leading to insomnia, anxiety, depression, poor tissue maintenance, and hypothyroid states.

Diminished hypothalamic function is linked to low levels of central serotonin, resulting in exaggerated levels of Substance P in the spinal cord, causing exaggerated sensations of pain ─Substance P (SP) is an undecapeptide [a peptide composed of a chain of 11 amino acid residues] member of the tachykinin neuropeptide family. It is a neuropeptide, acting as a neurotransmitter and as a neuromodulator. Substance P was found to function as the pain transmitter of the dorsal horn. The dorsal horn is composed of sensory neurons and is found on all spinal cord levels.

Adrenal stress may not only alter diurnal cortisol production, but may stimulate increased adrenalin, which is called norepinephrine. Norepinephrine is yet another hormonal neurotransmitter that can stimulate receptors that modulate the pain perception and response. Any or all of these hormonal imbalances could contribute to the complex fibromyalgia syndrome and perception of pain.

Myalgia after stopping hormone therapies

The deficiencies of normal hormone production account for a high incidence of systemic muscle pain after stopping hormone therapies of contraceptive or hormone replacement therapies. All fibromyalgia syndromes are not alike, but the syndrome may be related to this type of hormonal imbalance. If this is a possibility, a hormonal panel should be ordered to rule this in or out and treat the syndrome accordingly. Synthetic pharmaceutical hormones do not restore hormone production, but replace natural hormones instead, and inhibit the natural hormonal production. A physician trained in bioidentical hormone therapy can help restore the body to a functional state.

Vasomotor dysregulation, vasoconstriction and low-level ischemia

This has been shown to be the common thread in fibromyalgia patients. The exact cause, neurological, endocrine or immune is still being investigated. The most thorough course of treatment will address all the possibilities. The neurological cause would seem to be related to the autonomic nervous system. Standard allopathic medicine looks to an either/or approach and often misses the causes of systemic disorders when there is a complicated link between systems. A holistic approach would look to bring related systems back to normal function to correct the problem.

It is known that estrogen hormones, neuropeptides and the immune modulator nitric oxide all affect the peripheral muscle vasodilation and are controlled by a neuro-hormonal axis. Homocysteine levels also are highly related to vasodilation disorder, with higher plasma levels consistently noted in vasomotor dysregulation. Homocysteine is an amino acid formed from cysteine and methionine, and excess implies a metabolic imbalance related to deficiencies of Vitamins B6 -specifically P5P, B12, B9 -folic acid,  betaine, or stress of glutathione metabolism. Studies have found a consistent increased concentration of homocysteine in the cerebrospinal fluid of patients with fibromyalgia.

Folic acid + B6 (P5P) supplementation decreases homocysteine levels in most patients. B12 deficiency should be investigated also as a cause (B12 injections are the only sure way of supplementation, but use of sublingual supplements, especially liquid forms, DANG GUI, and improved diet may help). Selenium (methylselenocysteine) + VitE may be useful to reduce oxidative stress and improve vasomotor dysregulation. SAMe is a methionine that may also improve this imbalance. Green tea or green tea extracts (catechins) have been proven useful to lower homocysteine levels.

Sulfur deficiencies in fibromyalgia

Sulfur is an abundant nutrient in the human body and integral to a number of nutrient compounds found beneficial in fibromyalgia treatment, including SamE, MSM, DMSO, glucosamine sulfate, methionine, cysteine, cystine, homocysteine, homocysteine, and taurine. Sulfur deficiency and sulfur dysregulation are thus being explored. Sulfur containing foods include egg yolks, legumes, onions, garlic, turnips, nuts, kale, seaweeds, raspberries, radishes, watercress, and dark leafy greens in general, such as collards.

Sulfur is also a key ingredient of collagen formation and the health of connective or fibrous tissues. Sulfur is an essential nutrient in relation to methionine and cysteine. Alpha lipoic acid may aid in the sulfur metabolisms. Imbalance of the liver and amino acid system may be related to nutrient deficiencies of sulfur containing nutrients. While modern medicine thinks these approaches are without merit, historical use of sulfur and sulfur containing chemicals is abundant in medical use, including the use of sulfur baths to treat musculoskeletal disorders.

Recent studies have shown that the balneotherapy (high mineral concentrations of sulfur, selenium, silica and radium in hot water) at Dead Sea spas are proven effective for fibromyalgia therapy. Addition of herbal or essential oil infusions in the hot bath may have a similar result when combined with sea salts (pine needle oil, thyme, chamomile). Coagulation disorders and accumulation of fibrin proteins on blood vessel endothelium inhibits normal oxygen and nutrients to the muscles and prevents clearing of chemicals that trigger pain.

Things That May Cause Fibromyalgia

Prolonged or severe physical, emotional, or mental strain triggers the body to produce high levels of stress hormones, such as cortisol, and immune system mediators. In many patients with fibromyalgia, perhaps related to epigenetic propensity, this hyperactivation of the immune system appears capable of triggering an abnormal cascade of coagulation proteins, resulting in excess protein fibrins depositing on small blood vessel linings. Any number of stresses, including injury, surgery, childbirth, viral illness, or emotional trauma, could trigger a hypercoagulation state.

Some patients may produce excess clotting factor thrombin, some may produce lower levels of proteolytic enzymes that clear away excess fibrin proteins, and some may have chronic inflammatory states that create excess adherence of clotting fibrin to inflamed capillaries beds in muscles. Food allergies, intestinal dysbiosis, leaky gut syndrome, sluggish liver, chronic low-grade viral infections, yeast or fungi overgrowths, or accumulation of environmental toxins, could all trigger excess immune responses of the T-cell helpers type one (TH1) that lead to excess immune response of blood coagulation and fibrin accumulation. Fibrin accumulation and hardening of the small vessel walls could also be worsened with excess of advanced glycation endproducts ─AGEs─ (harmful compounds that stem from cooking foods at high temperatures and accumulate in the body as people age, and are a major cause of inflammation that can increase the risk of insulin resistance and type II diabetes). Attention to overall health and contributing health factors may be important in the treatment protocol.

Fibrin accumulation in large blood vessels may create thrombi, or blood clots, but in small vessels will create a stiff mesh that limits the amount of blood flow into the muscle tissues, and subsequently a deficiency in nutrient oxygen and other important tissue nutrients, such as calcium, magnesium, and the building blocks of ATP, the fuel for firing muscles. This leads to both a feeling of muscle fatigue, and stimulation of pain receptors. Not only are nutrients inhibited to the muscles with fibrin accumulation, but molecules that may stimulate pain receptors may also not be cleared effectively by the diminished local blood flow.

Both soft tissue mobilization and myofascial release, and the use of proteolytic enzymes, such as serratiopeptidase and nattokinase, will help to resolve this fibrin accumulation. Vitamin K (K1 and K2) may be deficient in the individual with excess fibrin accumulation and has been found to be protective of neurons subjected to methylmercury toxicity as well. Once the local vascular problems and nutrient dystrophy are corrected, the patient may benefit from a short course of super nutrient supplementation, such as D-ribose, which creates higher levels of ATP, as well as Vitamins B1 and B2. Unfortunately, if the underlying causes, and the mechanisms of abnormal pain sensitivity, are not also addressed, by neurohormonal restoration, this combination of tissue therapies may be limited and temporary. A comprehensive approach to the complex disease mechanisms is important.

Besides treatment directed focally at problems in the central nervous system and peripheral tissues, underlying dysfunctions may also need to be addressed. Restoration of adrenal and hypothalamic functions, hormonal balance, and the chronic causes of these dysfunctions, such as poor GI health, accumulations of neurotoxins such as heavy metals from the environment, chronic allergic and hyperimmune states, sleep disorders, and sluggish liver function, can all be addressed with a comprehensive protocol in Traditional Chinese Medicine. In addition, a number of mind-body therapeutics are now proving to be remarkably effective, including Qigong, Tai Chi, and Yoga.

Qi Gong is the therapeutic protocol in Traditional Chinese Medicine that has been highly developed, and is integral to the practice, both in the physician practice, and with instruction to the patient. This therapeutic protocol, originally called Yang Sheng, or nurturing vitality, involves a wide array of techniques that focus better mind-body coordination. Tai chi, is a type of Qigong, originally developed for athletic training, that refined the complex practice to more simplified protocols. The TCM physician is able to both incorporate Qigong into the treatments, and if requested, teach the patient how to focus Qigong exercises that would be most beneficial at home.

BIOMEDICAL PERSPECTIVE FROM THE MAYO CLINIC

Diagnosis
In the past, doctors would check 18 specific points on a person’s body to see how many of them were painful when pressed firmly. Newer guidelines do not require a tender point exam. Instead, a fibromyalgia diagnosis can be made if a person has had widespread pain for more than three months — with no underlying medical condition that could cause the pain.

Blood Tests
While there is no lab test to confirm a diagnosis of fibromyalgia, the doctor may want to rule out other conditions that may have similar symptoms. Blood tests may include:

Complete blood count
Erythrocyte sedimentation rate
Cyclic citrullinated peptide test
Rheumatoid factor
Thyroid function tests
Homocysteine level

Treatment
In general, treatments for fibromyalgia include both medication and self-care. The emphasis is on minimizing symptoms and improving general health. No one treatment works for all symptoms.

Medications
Medications can help reduce the pain of fibromyalgia and improve sleep. Common choices include:

Pain Relievers: Over-the-counter pain relievers such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may be helpful. Your doctor might suggest a prescription pain reliever such as tramadol (Ultram). Narcotics are not advised, because they can lead to dependence and may even worsen the pain over time.

Antidepressants: Duloxetine (Cymbalta) and milnacipran (Savella) may help ease the pain and fatigue associated with fibromyalgia. Your doctor may prescribe amitriptyline or the muscle relaxant cyclobenzaprine to help promote sleep.

Anti-seizure Drugs: Medications designed to treat epilepsy are often useful in reducing certain types of pain. Gabapentin (Neurontin) is sometimes helpful in reducing fibromyalgia symptoms, while pregabalin (Lyrica) was the first drug approved by the Food and Drug Administration to treat fibromyalgia.

Therapy
A variety of different therapies can help reduce the effect that fibromyalgia has on your body and your life. Examples include:

Physical therapy: A physical therapist can teach you exercises that will improve your strength, flexibility and stamina. Water-based exercises might be particularly helpful.

Occupational Therapy: An occupational therapist can help you make adjustments to your work area or the way you perform certain tasks that will cause less stress on your body.

Counseling: Talking with a counselor can help strengthen your belief in your abilities and teach you strategies for dealing with stressful situations.

Lifestyle and Home Remedies
Self-care is critical in the management of fibromyalgia.

Reduce Stress: Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say no without guilt. But try not to change your routine completely. People who quit work or drop all activity tend to do worse than do those who remain active. Try stress management techniques, such as deep-breathing exercises or meditation.

Get Enough Sleep: Because fatigue is one of the main characteristics of fibromyalgia, getting sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep habits, such as going to bed and getting up at the same time each day and limiting daytime napping.

Exercise Regularly: At first, exercise may increase your pain. But doing it gradually and regularly often decreases symptoms. Appropriate exercises may include walking, swimming, biking and water aerobics. A physical therapist can help you develop a home exercise program. Stretching, good posture and relaxation exercises also are helpful.

Pace Yourself: Keep your activity on an even level. If you do too much on your good days, you may have more bad days. Moderation means not overdoing it on your good days, but likewise it means not self-limiting or doing too little on the days when symptoms flare.

Maintain a Healthy Lifestyle: Eat healthy foods. Limit your caffeine intake. Do something that you find enjoyable and fulfilling every day.

Alternative Medicine
Complementary and alternative therapies for pain and stress management are not new. Some, such as meditation and yoga, have been practiced for thousands of years. But their use in the United States has become more popular in recent years, especially with people who have chronic illnesses, such as fibromyalgia.

Several of these treatments do appear to safely relieve stress and reduce pain, and some are gaining acceptance in mainstream medicine. But many practices remain unproved because they have not been adequately studied.

Acupuncture: Acupuncture is a Chinese medical system based on restoring normal balance of life forces by inserting very fine needles through the skin to various depths. According to Western theories of acupuncture, the needles cause changes in blood flow and levels of neurotransmitters in the brain and spinal cord. Some studies indicate that acupuncture helps relieve fibromyalgia symptoms.

Massage Therapy: This is one of the oldest methods of health care still in practice. It involves use of different manipulative techniques to move the body’s muscles and soft tissues. Massage can reduce heart rate, relax muscles, improve range of motion in the joints and increase production of the body’s natural painkillers. It often helps relieve stress and anxiety.

Yoga and Tai Chi: These practices combine meditation, slow movements, deep breathing and relaxation. Both have been found to be helpful in controlling fibromyalgia symptoms.

Cupping Therapy: Can it relieve fibromyalgia pain?
Some studies indicate that cupping may reduce fibromyalgia symptoms more effectively than conventional treatments.

Cupping therapy is a type of traditional Chinese medicine that involves creating a vacuum within glass cups placed on certain acupuncture points on the body. This can be done by heating the air within the cup before placing it on the skin.

The resulting suction pulls the skin and flesh part of the way into the cup. The cup may be left in place for several minutes and then removed, leaving behind a bright or dark red, circular welt. In wet cupping, the skin is pricked with a needle before the cup is placed and some blood is suction into the cup.

Proponents believe that cupping therapy can help increase circulation and promote healing. The procedure is generally safe when performed by trained professionals, but it can cause bruises, soreness, and burns.

Studies of cupping typically measure the effectiveness of the procedure by comparing it with that of other forms of treatment. However, high-quality research studies usually also include a group of people who receive a placebo.

Finally, while some of the available studies do suggest a possible role for cupping in treating fibromyalgia, the definitive answer to its actual role will have to wait for larger and more rigorous studies to be completed.

 

MISCELLANEOUS AILMENTS

TREATMENTS OFFERED

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-Mayo Clinic Staff. 

-Above Article Written by Dr. Osorio, Gloria, DAOM, L.Ac. 2020