By Victor Rosenfeld, MD
A 54-year-old woman with widespread pain, fatigue, and insomnia presents to the healthcare provider’s office with complaints of excessive daytime drowsiness. The patient noted that she developed chronic widespread pain and fatigue following routine gynecologic surgery to treat endometriosis in 1993. Since that time, she has been seen by numerous specialists, including rheumatologists, neurologists, urologists, pain specialists, and gastroenterologists.
Past Medical History
The patient was initially diagnosed and treated for systemic lupus erythematosus, although testing was inconclusive and she has never developed any classic manifestations of the disease. She initially rated her pain on a visual analog scale (VAS) as 9 of 10, but now says that it is about 4 of 10. She has many syndromes associated with fibromyalgia (FM), including irritable bowel syndrome, irritable bladder, migraine headaches, fatigue, temporomandibular joint (TMJ) pain, restless leg syndrome (RLS), non-refreshing, nonrestorative sleep, and myofascial pain.
A neurologist has managed the patient’s migraines with the use of intramuscular lidocaine and corticosteroid injections. To stop the migraine, the patient takes a triptan agent, usually with good success. Her past medical history is negative for cervical spinal trauma or psychosexual trauma.
The patient’s medication history includes failed treatment with duloxetine (Cymbalta) and milnacipran (Savella). Pregabalin (Lyrica) and gabapentin therapy produced weight gain and somnolence. Trazodone therapy caused excessive daytime sleepiness, zolpidem (Ambien) caused some complex sleep behaviors, and diazepam caused depression. Pramipexole (Mirapex) has helped her RLS and pain. Benadryl, which helps with sleep, exacerbates her RLS.
The patient’s current medication history includes tramadol 100 mg per night (Ultram); acetaminophen and hydrocodone (Vicodin), used sparingly; pramipexole 1.5 mg per night; clonazepam 0.5 mg per night (Klonopin); sertraline 25 mg/day (Zoloft); Tylenol PM, and zolpidem as needed.
The patient is a busy executive for a nonprofit organization who neither smokes nor drinks. She has a brother diagnosed with obstructive sleep apnea (OSA), but no family history of FM or RLS.
On presentation, the patient complains of excessive daytime drowsiness. Epworth Sleepiness Scale is elevated at 21. Fatigue Severity Scale is elevated at 50. The patient admits to problems with drowsiness during the day that affects her ability to function, including falling asleep at work and meetings, having near car accidents, and having to take frequent naps during the day.
Circadian rhythm is quite variable due to her work schedule and multiple sleep issues, but she usually goes to bed around 1:00 am, wakes up at 5:30 am, and uses sleep aids. She has been told that she stops breathing at night. She has gastroesophageal reflux, and wakes up with headaches. Her RLS is managed well with pramipexole 1.5 mg taken at bedtime and she wears a bite guard for her TMJ. There is no obvious evidence of hypersomnia or narcolepsy. Sleep hygiene is poor. Table 1 provides results from the physical examination and Figure 1 illustrates the results of the sleep hypnogram.
Diagnosis and Treatment Plan
Based on the results of physical examination and polysomnography (PSG), the patient was diagnosed with FM, RLS, insomnia, and severe OSA. The patient was started on a regimen of sodium oxybate (Xyrem) 3 g per night, given in divided doses, to help treat the pain, fatigue, and sleep problems associated with FM. Although not FDA approved for this indication, sodium oxybate has been shown in large Phase III trails to reduce pain and fatigue, and improve sleep and function in patients with FM.1
Since the patient is intolerant to continuous positive airway pressure (CPAP) devices, the severe OSA was treated with an oral appliance therapy with mandibular advancement. The patient was continued on pramipexole for RLS and told to avoid Benadryl. The patient was instructed on good sleep hygiene practices and was given benzodiazepine sparingly to treat insomnia.
The oral appliance therapy was effective for OSA in this patient, as evidenced by nocturnal pulse oximetry findings and resolution of sleepiness, but her TMJ was exacerbated. It was recommended that the patient consider turbinate surgery and retrial of CPAP (with or without sodium oxybate) to assist with pain and sleep. Her RLS remained and was treated with pramipexole and avoidance of Benadryl. Her insomnia improved, but sleep hygiene remains a persistent issue. The patient had a significant reduction in fatigue and nonrestorative sleep while on moderate doses of sodium oxybate (3 mg/night); higher doses produced increase side effects that outweighed any additional sleep benefit.
Last updated on: September 20, 2011
Fibromyalgia is a cyclic and progressive illness that affects millions of people regardless of age, sex or race. Symptoms vary but involve multiple body areas and are usually unrelenting, affecting various body systems, including the CNS, such as fatigue and depression; musculoskeletal, as in soft-tissue pain; gastrointestinal, as in IBS; dermatological; etc.Chronic fatigue syndrome (CFS) mimics many of the symptoms of fibromyalgia; however, CFS symptoms wax and wane in the form of flu-like symptoms. To differentiate CFS from fibromyalgia, the American College of Rheumatology established fibromyalgia classification criteria in 1990. An evaluation of 18 specific points on the body through pressure testing for tenderness is the basis for the differentiation from CFS and other conditions. Among a number of other criteria, this tender-point evaluation (the patient must test positive on at least 11 of the 18 points) validates the diagnosis of fibromyalgia.
In my professional experience working with fibromyalgia / CFS patients over the past 20 years, I have found three common denominators: 1) All fibromyalgia patients have multiple conditions. 2) The vast majority of fibromyalgia patients, 90 percent or more, also have CFS as a condition. Not all CFS patients, they are happy to tell you, also have fibromyalgia. 3) Fibromyalgia and CFS magnify the symptoms of concurrent conditions. They make them three to five times worse, in my estimation.
Mrs. DW entered my clinic in October 2007 for evaluation and treatment of multiple conditions including fibromyalgia and CFS, although these conditions had not been officially diagnosed. Mrs. DW, age 52, was working as a nurse in a local hospital. She stated that she had a difficult childhood that caused her to leave home at the age of 16. In her early 20s, she became ill with endometriosis and urinary infections which led to ovarian cysts, weight gain, depression, oopherectomy and appendectomy.
After surgery, she seemed to improve, enjoying her work as a nurse. Soon, however, she began to have trouble remembering things, along with irritability and sleep deprivation. Her joints began to hurt and she seemed to be in constant pain that progressively got worse over several years. Prescription pain medications did not help. Her doctors were frustrated, along with her husband, for lack of proper diagnosis.
She began seeing a chiropractor six years before coming to my clinic, who began to educate her on an anti-inflammatory diet, which seemed to help. As might be expected, what Mrs. DW yearned for was to be completely cured of whatever she had. She and I met at a physician pain and fibromyalgia seminar at the hospital at which she works. During the seminar I had the opportunity to introduce the protocol I had been using to successfully treat these same patients. Since my protocol was quite different than those proposed by the allopathic physicians, Mrs. DW approached me with the possibility of her coming to my clinic for an evaluation.
Initial examination on Mrs. DW included completion of the American College of Rheumatology 1990 Classification Criteria for Fibromyalgia to validate her diagnosis. Upon completion of testing, the patient proved positive in all areas, including 16 out of 18 specific points of tenderness. Therefore, her initial diagnosis was fibromyalgia and chronic fatigue syndrome, separate from any other diagnosis at this point.
This examination was followed by a thorough orthopedic and neurological evaluation for her secondary conditions. Separate from Mrs. DW's fibromyalgia and CFS symptoms, the patient complained of low back pain radiating into both lower legs (posterior) and neck pain radiating into both arms, along with head pain. Symptoms also included intermittent numbness, dizziness, muscle spasms, loss of balance, and many others which might have been affiliated with fibromyalgia / CFS. Positive findings from these tests validated a lumbosacral condition, along with a cervicobrachial condition separate from the fibromyalgia / CFS diagnosis.
The treatment plan for Mrs. DW consisted of two separate programs. The first involved ridding the patient of the secondary conditions in the neck and lower back. Since these were chronic conditions, I explained that an aggressive period of treatment including chiropractic adjustments, physiotherapy, acupuncture and rehabilitation was called for to elicit functional improvement in the spine as soon as possible. This would help separate the fibromyalgia and CFS conditions and their symptoms from the secondary spinal conditions.
As we began this initial spinal treatment, we also introduced the protocol for fibromyalgia and CFS. The protocol is a combination pre-protocol anti-inflammatory dietary program and a protocol developed by Dr. R. Paul St. Amand. The protocol relies on an innocuous substance called guaifenesin along with the strict avoidance of all salicylates that block the positive action of guaifenesin. The guaifenesin pre-protocol was developed at the Fibromyalgia Research Center in California, a nonprofit center.
The anti-inflammatory dietary program involved a restricted hypoglycemic diet along with high levels of omega-3, EPA and DHA, magnesium (which stimulates the mitochondria), malic acid (another anti-inflammatory), conjugated linoleic acid, along with a liver detox program. This had an excellent initial response. Within two weeks ,the patient's fibromyalgia and CFS symptoms had improved appreciably. Her spinal conditions improved more slowly, but did show improvement. The patient's "fibro fog" was reduced, her energy increased, joint and muscle pain improved, and her IBS, bloating and gas all but disappeared.
Within two months of introducing the entire protocol, the patient had lost 13 lbs and two dress sizes. Weather changes did not negatively affect her. Her mood swings hardly swung, she smiled a lot and her humor had resurfaced, along with a much more enjoyable relationship with her husband. After two years, five months, nurse DW is seen only for structural problems due to her normal activities of daily living. Fibromyalgia and CFS symptoms abated completely after four months.
It is important to differentiate the fibromyalgia / CFS from other conditions the patient may have in order to treat them separately and evaluate symptomatic changes. As stated, fibromyalgia / CFS conditions magnify other secondary conditions and their presenting symptoms. Treating secondary conditions, especially chiropractic spinal or extremity conditions, aggressively is very important in the overall treatment plan.
Once the fibromyalgia/CFS pre-protocol and protocol is established it is the primary responsibility of the patient to stay on protocol at home. Educating the patient and having a strong commitment to the overall program is as important as the protocol itself. This treatment protocol has worked successfully for numerous Fibromyalgia/CFS patients that come to our clinic
After many years of trial and error working with many patients, I have found the above treatment protocol to be extremely successful helping patients like nurse DW achieve a normal state of living. Patients are now returning to work and enjoying activities previously only dreamed of, such as unrestricted exercise and vacationing, with no negative symptomatic reactions. Normalcy is indeed within their grasp.
Dr. Kenneth Muhich practices at Stetson Chiropractic Clinic in Scottsdale, Ariz. Contact him with questions and comments regarding this article via his practice Web site, www.stetsonchiropractic.com.
Next Article in Issue
Next Article in Topic
Previous Article in Issue
Previous Article in Topic