Kay was only 59, but she felt as though her life might as well be over. Though she had sought help from numerous medical specialists, she had been in chronic daily pain for several years. Eventually, in 1991, after extensive tests through the University of Washington and the Chronic Fatigue Clinic at Harborview Hospital in Seattle, she was diagnosed with fibromyalgia.
Resorting to antidepressants as her mood spiraled downward, Kay tried many different drugs to attack her symptoms. “Neither my primary physician nor a rheumatologist had been able to offer much besides pain and sleep drugs and a cortisone shot in the shoulder,” she told me. Kay’s shoulder pain was so severe that bending down to grasp a pebble and tossing it away would leave her in intense pain for a day.
Kay also had pervasive fatigue and seriously disturbed sleep, dizziness, allergies, depression, bowel problems and shortness of breath. She had become resigned to her fate. Finally, in a last desperate search for results, Kay came to see me.
She began a rebuilding program of herbs and vitamins and made improvements to her diet. And at long last, things began to change. Within two weeks, she was feeling a little better. Her breathing was easier and her pain was lessening. Her other symptoms began to respond, too, and she experienced strengthening and flexibility of her muscles, good digestion, better sleep and regrowth of her hair and nails, which had been damaged by the illness. After six months of consistent effort and carefully selected herbs, she was pain-free for the first time in many years.
Dubbed fibrositis in 1904, the condition was originally believed to be caused by inflammation of the connective tissues. By 1943 the Mayo Clinic listed fibrositis as the most prevalent type of acute and chronic rheumatism. Even so, the disease was largely ignored. The syndrome was a slippery collection of seemingly unconnected problems, and widespread acceptance of the legitimacy of the diagnosis in mainstream practice was slow in coming.
In the mid-1980s, joint specialists began to turn their attention to the syndrome. Eventually, the mainstream medical community began to take notice, and diagnostic standards for fibromyalgia syndrome (FMS) were established. The current name reflects today’s understanding that it is not inflammation in the tissues that is the problem, but unaccountable pain (myo means muscle; algia means pain).
FMS is being diagnosed at an ever-increasing rate. It currently afflicts 2 percent to 4 percent of Americans. Women patients outnumber men by seven to one. Age is a risk factor — only 1 percent of 20-year-old women are affected, while more than 7 percent become stricken by age 70. FMS is characterized by fatigue and chronic, generalized muscular pain — usually in specific well-known areas. After osteoarthritis, FMS is the second most common arthritis disorder, even more common than rheumatoid arthritis. FMS is distinct from other forms of arthritis, even though it may occur along with them. A person with rheumatoid arthritis, for example, might also have FMS, and no cause-and-effect connection can be found, according to orthodox medicine. Even when the rheumatoid condition is successfully treated, the FMS may remain. Mainstream medicine verifies inflammatory forms of arthritis with blood tests, and degenerative forms (such as osteoarthritis) with X-rays. FMS produces no obvious laboratory signs. Routine blood tests are negative in most sufferers. From the conventional medical perspective, FMS symptoms have no obvious cause or connection. Many medical doctors, when they can’t find an organic cause, begin to think of psychological ones.
Unlike a discrete disease entity, like an ear infection or tuberculosis, FMS is a “syndrome,” a loose collection of symptoms that tend to occur in clusters, and the true underlying connections between them are not completely understood. The list of symptoms associated with the syndrome is long, and it is entirely possible for two different people with FMS diagnoses to share not a single symptom.
FMS consists of a constellation of chronic, often disabling, symptoms, including deep aching in the muscles, burning, stabbing, throbbing pains and profound, draining fatigue and muscular weakness. Many people feel the worst pain at certain well-identified “tender points” — spots that hurt when moderate pressure is applied.The pain in these areas often radiates so generally that sufferers are frequently unaware of their exact location until they are examined by a health practitioner. Many such points have been discovered by researchers, but 18 of them are so common to the disease that they are actually part of the diagnostic criteria. Of these specific 18 spots, a person must have tenderness in at least 11 spots to officially qualify as having FMS.
FMS can also involve a host of other disagreeable problems — as we saw in Kay’s example — including chest pain, headache, tingling, dizziness, constipation, diarrhea, gas, abdominal pain, water retention, premenstrual syndrome, menstrual cramps and poor memory. Sleep problems are the most common additional symptom of FMS I see in my practice. Nighttime problems can involve restless legs (twitchy, painful, cramping legs that make sleep difficult), irritable bladder and nocturnal myoclonus (jerky muscles).
FMS doesn’t seem to cause deformity or tissue damage, as other forms of arthritis do, but it can severely impair a person’s functioning. Victims often have bouts of incapacitating pain and fatigue, lasting weeks or months, only to improve mysteriously after a while. This unaccountable waxing and waning of symptoms, without an apparent pattern, is quite characteristic of the disease. Symptoms are often worse when the individual is sick (such as with a cold) or after heavy exercise.
Fibromyalgia’s cause remains elusive. Some researchers have suggested a hereditary link, and many other theories are floating around. Because FMS symptoms are so varied, each one is also possibly caused by another disease. Thus, the fatigue may be caused by thyroid conditions, whereas the joint pain may reflect other types of arthritis. Researchers are attempting to link FMS to various possible causes, and the truth is — as with other broad-spectrum syndromes — that the cause probably involves many contributing factors.
One group of researchers thinks FMS may be caused by forceful trauma, such as an auto accident or a ski injury, which deeply damages the central nervous system in an as-yet-unknown way. Somehow, they theorize, this damage results in the FMS symptoms, particularly the pain, which has no other known cause. Another theory involves infection. Certain infections (notably viruses, and especially influenza) occur more often in the histories of FMS patients. We know that flu causes joint pain. As these viruses invade the body, scientists think they may cause deep damage at a cellular level. FMS may end up being a very long case of the achy flu.
While at this time no one says that FMS is an infectious disease, per se, and is not contagious in the usual sense, it’s possible that it is the end stage of a virus disease, such as the flu, which is contagious. It is also possible that FMS is caused by a unique virus, heretofore undiscovered, so it could eventually be determined to be transmissible. Lack of exercise, with its weakening of muscle tone, may play a role. As muscles become less active, they are unable to flush blood and lymph through their cells. Old, tired muscles get achy. Because exercise often improves FMS, this is a likely possibility. Many medical doctors have noticed a strong link to hypothyroidism in patients with FMS. It is well accepted that low thyroid function causes fatigue and joint pain. Clinically, these practitioners are finding that improving thyroid response, or prescribing thyroid hormone, gives good results.
The current front-runner in the scientific community is a theory regarding neural hormones and their effects on pain and fatigue. Neural hormones, compounds in the central nervous system, control basic functions such as pain and blood flow. Recent studies have demonstrated that FMS sufferers, particularly older women, have a lower level of somatomedin C, a hormone produced in the liver in response to growth hormone. Somatomedin C is used by the body at night for tissue repair and is secreted by the pituitary in the deepest phase of sleep.
Research also suggests that FMS patients have a lowered pain threshold and that the nerve cells that fire in response to pain stay activated for too long.
In my discussions with practitioners of every type treating FMS, the overwhelming consensus is that this disorder is a result of a profound sleep disturbance. When we sleep, for about one hour in the dead of night, our muscles relax completely. During this short time, the muscles are able to heal at the deepest level — circulation of blood and lymph reaches the deepest cells. If sleep is disturbed, and the muscle remains the slightest bit tense, this healing is impaired, which begins a cycle of chronic subclinical damage that eventually escalates into the physical and mental symptoms of FMS.
Orthodox medical treatments for FMS revolve primarily around the use of tricyclic antidepressants to improve sleep. While these drugs themselves have side effects and other known disadvantages, they can sometimes help with sleep disturbances. Mainstream practitioners may also use nonsteroidal anti-inflammatory drugs (such as ibuprofen), prescribe analgesics for pain or inject an anesthetic into the patient’s tender points.
Exercise is a critical element in healing from FMS, although, with the severe pain, it may be difficult to begin a program and maintain motivation. However, keeping it up has its rewards: Exercise loosens stiffness in underused muscles, brings fresh blood into the joints and muscles and improves pain overall. Since the tissue is not actually damaged in FMS, even intense exercise seems pretty safe if it is introduced gradually.
A Swedish study from 2002 used a pool exercise therapy program for six months. When the scientists evaluated the patients two years after the program, they found lasting improvements in symptom severity, physical function and social function.
Many natural practitioners agree that magnesium is the single most important therapeutic tool in managing FMS. Magnesium deficiency is, by some accounts, the most common nutritional deficiency in the United States. Magnesium is abundant in our soils yet is now scarce in our food supply. Research shows that FMS patients are usually very low in magnesium, which is one of the most crucial nutrients for the production of ATP, the source of energy in muscle tissue. For this reason, some experts have proposed the name “energy deprivation syndrome” rather than fibromyalgia, which implies pain only in muscles and fibers. Low tissue magnesium apparently turns up the pain-signal volume.
I have seen magnesium produce improvement in one week in cases of FMS when numerous other therapies, including antidepressants, have failed. Some of these patients had suffered with the disease for 10 or 15 years. Magnesium is stool-loosening (remember Milk of Magnesia?), so use it carefully. Most FMS patients are constipated, so using magnesium can have a double benefit. Use the magnesium to bowel tolerance — the maximum dose that is not quite too stool-loosening. In most people, that dose is around 1,500 mg per day. Foods rich in magnesium include dark-green vegetables, legumes, nuts and seeds.
Because magnesium is very successful in FMS patients, and because magnesium is necessary to block the toxic effects of aluminum in the body, some experts theorize that aluminum toxicity may play a role in FMS. At the very least, it would be prudent to reduce your aluminum exposure as much as possible. Aluminum comes mostly from aluminum cookware and antiperspirants. Also, using a maximum dose of magnesium helps offset possible aluminum damage.
Kava (Piper methysticum) is an effective herb for FMS, with all the right qualities in one package. An excellent analgesic, its potency ranks between aspirin and morphine, and kava treats anxiety without dulling the senses. It is a muscle relaxant and a superb sleep aid, with sleep-enhancing effects that last about six to eight hours. Unlike tranquilizers, it does not create a morning hangover. Because the active ingredients in kava are not water soluble, a tincture with a high alcohol content (85 percent) often works best. Start with 1 teaspoon at bedtime and work up to 1 tablespoon as necessary for a pain-free, rejuvenating night’s sleep. Recent reports have linked kava extracts with liver damage. Although it’s not certain that the kava was to blame, use this herb with caution — under the guidance of your health-care provider — until the issue is resolved.
Turmeric root (Curcuma longa) is a standby in Asian herbal medicine, particularly in Ayurveda, where it is thought to benefit the musculoskeletal system. Curcumin, turmeric’s active compound, also treats pain directly. Like another medicinal spice, cayenne (Capsicum annuum), curcumin depletes nerve endings of substance P, the pain receptor neurotransmitter. New research shows that curcumin and related compounds suppress pain through a mechanism similar to many drugs (COX-1 and COX-2 inhibitors).
Turmeric is a mild herb — there are no special safety concerns with this medicine. For acute episodes, you might try a dose as high as 1 ounce (4 tablespoons) per day. Stir the powder into water and swallow, or make it into a paste with honey or a bite of oatmeal. It won’t taste great in this dose, but it’s a great medicine. For ongoing health benefits, use 1 gram (about 1 teaspoon) per day as a spice, or in capsules. Standardized extracts are available. The dose is 1,500 mg of total curcumin content per day. My patient Kay found that she got rapid benefit from, in particular, turmeric and magnesium therapy.
Willow bark (Salix spp.) is nature’s aspirin for joint pain. Willow is a traditional pain reliever that still lives up to its reputation. Willow contains salicin and other related salicylates (pain relievers that also lower fever and diminish inflammation), which are the herbal forerunners of aspirin. Willow is widely used in Europe for the treatment of low-back pain. Use a tea brewed from up to 1 ounce, dry weight, of the raw herb per day, or an extract containing 240 mg total salicin per day. Willow can be used for as long as necessary.
Some FMS sufferers claim to have experienced benefit from ginkgo (Ginkgo biloba) and Coenzyme Q10. A small pilot study in 2002 tested this combination. Patients took 200 mg of CoQ10 and 200 mg of ginkgo extract daily for 84 days, and 64 percent reported that they felt better.
Other herbs are also candidates for FMS treatment. Consider these:
• Gingerroot (Zingiber officinale) increases circulation to muscles; take 1 to 10 grams per day.
• Cayenne increases circulation and relieves pain; take up to three 500-mg capsules per day, but use caution — it’s spicy. Some of my patients find that even one capsule is enough to cause a burning sensation in their stomach. I suggest starting with 1/4 of a capsule and increasing to the amount that’s effective without being uncomfortable. You can also sprinkle cayenne powder on your food, as long as you can take the heat (1/4 teaspoon of cayenne powder is equal to about 400 mg).
• Boswellia gum or Indian frankincense (Boswellia serrata) reduces pain; take a product standardized to 65 percent boswellic acids, 300 to 1,200 mg per day.
• Guggul gum (Commiphora mukul) is the main Ayurvedic herb for arthritic diseases; try 2 to 10 capsules per day, 600 mg per capsule.
Many FMS patients gain tremendous relief from massage therapy with the addition of herbal ointments. Massage increases flexibility and oxygenation of the muscles and brings fresh blood and lymph to the sore areas. The herbal salves that have the greatest effect, say FMS patients, contain either menthol or cayenne extract. In a German study from 2001, a cayenne plaster decreased nonspecific low-back pain substantially. The ointments can be rubbed on sore muscles or only on the tender points. Some people have told me that the massages were the difference between walking or not walking on any given day.
Major diagnostic criteria
• Widespread pain in all four quadrants of the body lasting for at least three months
• Tenderness in at least 11 of the 18 specified tender points (see Page 27 for an illustration of the points)
• Generalized aches or stiffness of at least three anatomic sites for at least three months
• Exclusion of other disorders that are known to cause similar symptoms
Minor diagnostic criteria
• Generalized fatigue
• Chronic headache
• Sleep disturbance
• Neurological and psychological complaints
• Joint swelling
• Numbing or tingling sensations
• Irritable bowel syndrome
• Variations of symptoms in relation to activity, stress and weather changes
• Temporomandibular joint syndrome (TMJ)
Karta Purkh Singh Khalsa is an adjunct faculty member in the botanical medicine department of Bastyr University. He is currently writing a new book on Ayurvedic herbalism.