How your body is able to use the fat depends on whether it is a saturated fat or an omega-3 or omega-6 fatty acid. In many processed foods (for example, margarine) the unsaturated fats are changed from their healthy natural state, in which they are known as cis-fatty acids, to an unnatural unhealthy state, in which they are called trans-fatty acids. These trans-fatty acids can cause heart disease, obesity, immune suppression, and decreased testosterone levels, while worsening fatty acid deficiencies. Despite advertising hype to the contrary, margarine is probably less healthy than butter, and I recommend not using it.
Differentiating between these fats is important because they are the building blocks of cell membranes, the balloonlike walls that enclose all cells in the body. These membranes perform the critical functions of allowing in and keeping in water, minerals, and other nutrients. In addition, the regulatory hormones and neurotransmitters—molecules that tell the cells what they need to do—function by fitting into receptors located in the cell membranes. The membranes are made up of fatty acids and a phosphorus molecule, usually choline or serine. The type of fat available to your body when it makes cell membranes is critical. Your body likes to use omega-3 and-6 fatty acids because these are more fluid and more easily allow the passage of hormones, neurotransmitters, and other fluids in and out of the cells. However, when omega-3 and omega-6 fatty acids are not available, your body has to use saturated fats. This results in rigid, poorly functioning cellular walls that can make it hard for the hormones and neurotransmitters to function properly.
EFAs are also critical for making an important class of hormones called prostaglandins. These hormones regulate inflammation, pain, bowel function, fluid balance, mood, allergies, and the production of some other hormones. Because of its effect on prostaglandin levels, borage or evening primrose oil can help PMS as well. For more information on these and EFAs in general, see the From Fatigued to Fantastic! notes at www.vitality101.con.
To treat possible essential-fatty-acid deficiency, I recommend taking Eskimo-3 (Enzymatic Therapy) or omega-3 (Ultraceuticals) fish oils, which are mercury and toxin free, at a dose of three to nine capsules a day. Take these for three months. If dry skin, dry hair, dry mouth, and/or dry eyes improve, then you probably had a fish oil deficiency. After three months, you can decrease the above regimen to three capsules of fish oil a day and/or three servings a week of tuna, salmon, or herring. As an added benefit, fish oil helps people’s moods. For example depression that does not respond to Saint John’s wort or antidepressant medications will sometimes improve with omega-3 fatty acids.
BODYWORK
There are many forms of bodywork that can eliminate pain by stretching your tightened muscles. My favorites include Trager, Rolfing, myofascial release, chiropractic treatments, and acupuncture. Some physical therapists are simply too rough or unfamiliar with fibromyalgia and can aggravate symptoms. If any bodywork therapist hurts you, let them know so they can ease back and work more gently. Remember, “No pain, no gain” is a good recipe for hurting yourself. However, a skilled practitioner can effectively help you treat your illness. As you research which techniques and practitioners, are right for you, keep these guidelines in mind:
Rolfing should be done only by a certified Rolfer with a lot of experience, as some people with minimal training claim that they do Rolfing and can work too aggressively.
When talking with a physical therapist, ask if he or she knows how to do Dr. Janet Travell’s spray-and-stretch technique. This approach uses a cold spray to briefly block pain, allowing the muscle to be easily and comfortably stretched. This technique takes time to learn, and knowledge of the technique may indicate a more thorough, dedicated practitioner. Structural issues and trigger points that may contribute to pain will be discussed later in this chapter.
Prolotherapy is a technique that may relieve joint pain in people with loose ligaments who can hyperextend their joints and have “loose,” elastic skin. The technique consists of injecting weak ligaments with a substance that causes inflammation. The end result of this therapy is to strengthen the ligament, thereby reducing pain. For a detailed article on prolotherapy, see the From Fatigued to Fantastic! notes at www.vitality101.com.
Magnets have been helpful for many patients with pain. Although some physicians feel they are simply placebos (and some poorly made ones are), research has shown that they can increase blood flow to painful areas and decrease pain. I generally recommend starting with spot magnets for localized areas that hurt a lot, as well as magnet shoe insoles and the universal chair pad. If the spot magnets help in two months, then consider purchasing a mattress pad. The mattress pads are more expensive and, for some patients, too strong to start with. Many people, though, have been pleased that they started with a mattress pad because it offered substantial relief. A number of different companies sell magnets and related products (see Appendix E: Resources).
Prescription Medications
Although natural remedies can be helpful, the pain experienced by fibromyalgia patients is often severe enough to warrant the addition of prescription therapies. All of the natural therapies I’ve discussed can be combined with the prescriptions below, and can decrease the amount of medication needed while increasing safety and decreasing side effects. I also discuss how to treat other pains commonly seen in fibromyalgia, such as nerve pain, migraines, and arthritis. As always, I recommend working with a holistically trained physician who is familiar with both natural and prescription therapies.
PRESCRIPTION PAIN CREAMS AND LOTIONS
Many people with fibromyalgia also have a few painful body areas that are especially distressing but they shy away from taking pills, as they are sensitive to prescription drugs. That’s why I often recommend topical pain lotions. After two weeks of use, you can actually get the same tissue concentrations in the local muscles and tendons topically as you can when taking medications by mouth—without the side effects. Many compounding pharmacies make these topical pain gels/lotions/creams (regular pharmacies are usually not familiar with them), and they are happy to guide your physician. I like to use ITC Pharmacy (see Appendix E: Resources). Simply ask your doctor to call them to prescribe the pain lotion or if you have nerve pain, the nerve pain lotion. These typically include five to six pain medications. By rubbing a thin layer of the lotion or gel into the skin over painful areas, you can often eliminate your worst pain spots. Sometimes using these products for seven to fourteen days in one spot will relieve the pain, or even make that area of pain go away permanently—and then you can march through other pain spots, eliminating them a few at a time. You can use these products on up to three or four silver-dollar-size areas at a time, three times a day. The cost is approximately sixty-six dollars for a 30-gram tube, which lasts quite a while. For a more detailed discussion of the many topical pain options available (and other pain issues), see my book Pain Free 1–2–3.
PRESCRIPTION ORAL MEDICATIONS
Tramadol (Ultram). I have found tramadol to be the single best pain medication for fibromyalgia. It affects both serotonin and endorphin (narcotic) receptors, and is considered minimally addicting, although I’ve never seen addiction with it in my practice. The recommended regimen is one to two 50-milligram tablets up to four times a day as needed for pain. The most common side effects are nausea and vomiting (when people use more than six tablets a day), and sedation. These effects generally wear off with continued use, and can often be avoided altogether by starting with a low dose and slowly working up to the level that most effectively treats your pain.
MUSCLE RELAXANTS
Metaxalone (Skelaxin). This muscle relaxant is nonsedating and is helpful in around half of the fibromyalgia population. You will usually know within one week whether Skelaxin will work for you. Take one 800-milligram tablet four times a day as needed for pain. It can be taken with Ultram.
Tizanidine (Zanaflex). This muscle relaxant can be sedating, so many people take it at night to relieve the pain, spasms, muscle cramps, and tightn
ess that may inhibit sleep. The usual dose is one 4-milligram tablet up to three times a day for pain. Zanaflex can sometimes cause nightmares; if this occurs, discontinue use, as the problem usually does not go away until the medication is stopped. Do not take it (or lower the dose to 2 to 4 milligrams) while on the antibiotic Cipro.
ANTIDEPRESSANTS
Antidepressants such as venlafaxine (Effexor), duloxetine (Cymbalta), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft), tried in the order listed, can sometimes be effective in treating fibromyalgia pain—even when no depression is present. In fact, most of the CFS/FMS patients I treat with antidepressants are not depressed. However, these medications are effective because they raise serotonin, which lowers the chemical that transmits pain (called substance P). It takes six weeks to see their full effect.
It’s best to start with low doses and then work up to higher doses to see the optimum effect. This is especially true if you are taking Effexor for nerve pain, which often takes 225 milligrams per day to work. Your doctor can help you establish the best dose. Although drug interactions are possible, I have not found this to be a major problem. If you have a chronic fast heart rate and anxiety, however, these can be exacerbated when serotonin levels go too high because of serotonin-raising treatments—especially when several of them are taken together. This is called serotonergic syndrome and can be life-threatening. As I discussed earlier, for patients with a fast pulse, I recommend that all serotonin-raising medications be reviewed and, if needed, the doses lowered for about a week to see if the heart rate comes down. If the heart rate does indeed drop, your doctor will need to adjust your medications.
Some of the more common treatments that can raise serotonin include:
Almost all of the antidepressants (including Elavil)
Trazodone (Desyrel)
Tramadol (Ultram)
Saint John’s Wort
Tryptophan or 5-HTP
TRICYCLIC ANTIDEPRESSANTS ( AMITRIPTYLINE, DOXEPIN, ETC.)
AMITRIPTYLINE (ELAVIL ) is especially good for nerve pain, pelvic pain, vulvadynia (pain in the vulvar area), interstitial cystitis, and proctalgia fugax (episodic rectal pain due to muscle spasm). The main side effects are weight gain, sedation, restless leg syndrome, heart palpitations, and dry mouth. Elavil can also worsen neurally mediated hypertension (NMH), a type of low blood pressure syndrome experienced by some people with CFS/FMS. Because these medications, except doxepin (Sinequan), tend to be high in side effects, I use them mostly for severe nerve pain and pelvic pain syndromes.
INTRAVENOUS (IV) NUTRIENTS AND LIDOCAINE
Intravenous treatment with the anesthetic lidocaine, especially when given with intravenous nutritional therapies (called the Standard IV at the Fibromyalgia Fatigue Centers or more commonly known as Myers cocktails), can be a blessing for both easing muscle and spastic colon pain and helping raise energy levels in people with CFS/FMS. (For more information about Myers cocktails, see Appendix G.)
Intravenous lidocaine may first be given in a test dose of 40 to 50 milligrams infused over a thirty-minute period. The Myers cocktail can be given at the same time, in a different IV bag but through the same needle. If the lidocaine is well tolerated, you can take 100 milligrams the first day, as long as your blood pressure remains stable and there are no severe side effects. The treatment can be sedating—a sleepy feeling is common, and I often let patients take a nap on the table afterward—and you should not drive after a lidocaine infusion.
If the first treatment is well tolerated, we give a maximum of 100 to 120 milligrams an hour to a dose of 300 to 400 milligrams at a sitting, if needed. The effect seems to increase over the first four times that it is given. I usually infuse a dose of at least 200 milligrams during a single two-hour session before deciding that it is not effective for a particular patient.
Intravenous lidocaine can be taken as often as needed. Many people find that they need a treatment every one to three weeks. If lidocaine is administered at much higher doses than those mentioned here, abnormal heart rhythms or seizures can result, so at higher doses patients are sometimes hooked up to a heart monitor during the treatment. Some people feel that giving lidocaine without a monitor is controversial, but in my experience, at low levels it has been quite safe, and IV-administered lidocaine has been found to be safe and effective for pain in many studies and reports.27–30
Lidocaine can also be used in topical creams, but I do not find it to be effective this way. However, using a patch containing lidocaine that you apply over painful areas can be helpful. This patch is called Lidoderm and is available at any pharmacy by prescription. You can exceed the labeled dose slightly, using up to four patches at a time and leaving them on for up to sixteen hours a day. Give it two weeks to see the full effect, though it usually works more quickly.
NEURONTIN, GABITRIL, AND LYRICA
These medications work by increasing the effect of gamma-aminobutyric-acid (GABA), a “calming” neurotransmitter (brain chemical). They are often effective for fibromyalgia pain, allodynia, pelvic pain syndromes, and nerve pain, and are helpful for sleep and restless leg syndrome (see Chapter 3). They are not addictive but, like any medication, should be tapered off slowly if they’ve been taken for more than two to four months. I prefer to prescribe Lyrica only if Neurontin and Gabitril are not effective, as Lyrica is more expensive and can cause marked weight gain in some people. Lyrica can be very effective, however, and may be the first medication to be specifically approved by the FDA for treating fibromyalgia, and it is currently under review for this indication.
These natural and prescription therapies for fibromyalgia pain are generally highly effective. Nonetheless, some people have more persistent and severe pain, and it is important to note that there are dozens of other effective treatments as well, but they are simply beyond the scope of this book. For more information on these, I refer you to my From Fatigued to Fantastic! notes at www.vitality101.com (use the password FFTF) or my book Pain Free 1–2–3. In addition, these sources contain detailed information (and the numerous scientific study references supporting them) on how to eliminate many different kinds of pain. These include:
Nerve pain
Arthritis
Migraine and tension headaches
Osteoporosis
Back pain
Pelvic pain
Indigestion
Spastic colon
Carpal tunnel syndrome
In most patients, these can be relieved effectively (and without surgery) using a mix of natural and prescription therapies.
Structural problems can also contribute to pain (e. g., uneven hip heights), and treating these can be very helpful. We will finish this chapter with a brief discussion of these issues, followed by an exploration of trigger points and myofascial pain by Dr. Hal Blatman, a highly respected pain specialist.
Structural Issues
Although herbal therapies and medications may often eliminate fibromyalgia pain, it is also sometimes necessary to treat structural problems. For example, if the left hip is higher than the right hip, the left shoulder is often lower than the right shoulder. This is the body’s attempt to maintain balance, but it puts a significant strain on other muscles. Using a small insert (for example, a heel lift or orthotic) in the shoe of the short leg to make the hips the same height can help those strained muscles and eliminate one of the causes of pain. Or, if you find that one hip is lower than the other when you sit, using a cushioning support under the low side of your behind will make the hips more even, again reducing strain on overtaxed muscles. Many possible structural issues may be contributing to muscle spasm and pain; often, a chiropractor or a physical therapy physician (a physiatrist) can be of benefit. As noted earlier in the chapter, there are many different types of structural therapies.
A form of neuromuscular reeducation called Trager, developed by Dr. Milton Trager, has been beneficial for my more severe fibromyalgia patients. If your fibromyalgia persists despite the treatments
discussed in this book, you should consider calling the Trager Institute (see Appendix E: Resources) to locate the closest practitioner. The best kinds of Trager practitioners are instructors and tutors, who have reached a high level of expertise in the technique.
Rolfing is another technique that can be effective for FMS pain. Also known as structural reintegration, Rolfing is deep-tissue manipulation and massage. It is designed to relieve muscular and emotional tension and rebalance muscles. If done right, it can be comfortable; if done incorrectly, it hurts. A lot of people who say they are Rolfers are not fully trained in the technique. If someone does something that hurts, tell him or her to stop. The one exception to this is a different technique called ischemic compression, in which the practitioner pushes on a spot with thirty pounds of pressure for forty-five seconds. It hurts like hell, and then feels better. You can also do this on your own more comfortably using a device called a Thera Cane (see Appendix E: Resources). This simple and often overlooked technique can be helpful for treating tender spots. If you push on these spots for thirty to forty-five seconds, applying about twenty to thirty pounds of pressure (for example, with your thumb), they will often be tender and then the pain will subside. This can often be done in the context of a massage. Although not recommended for dozens of tender areas at one time, it can be helpful if a few nagging spots remain after treatment. To locate a Rolfing practitioner in your area, contact the Rolf Institute (see Appendix E: Resources).
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