Fibromyalgia and Global Pain Syndromes · Fibromyalgia and Global Pain Syndromes Central...

Dr. David M. Brady-Copyright 2018

Fibromyalgia and Global Pain Syndromes

Fibromyalgia and Global Pain Syndromes:

A Functional and Integrative Approach

• Naturopathic Doctor (ND)Licensed in CT and VT

• Doctor of Chiropractic (DC)

• Certified Clinical Nutritionist (CCN)

• Diplomate of the American Clinical Board of Nutrition (DACBN)

• Institute for Functional Medicine Certified Practitioner (IFMCP)

• Vice Provost, Health Sciences Director, Human Nutrition InstituteAssociate Professor of Clinical SciencesUniversity of Bridgeport, Conn.

• Chief Medical Officer,‐Designs for Health, Inc.‐Diagnostic Solutions Laboratory, LLC

• Private Practice (Fairfield, CT) Whole Body Medicine

Dr. David M. Brady



• Chief Medical Officer: Designs for Health, Inc. (DFH)

• Chief Medical Officer: Diagnostic Solutions Labs (DSL)

• Consultant: Cell Science Systems, Inc. (CSS‐ALCAT)

Disclosures



• “Fibrositis” (Sir William Gowers, 1904)

• “Psychogenic rheumatism” (circa 1950)

• “Fibromyalgia” (Current)

• “Central allodynia” (Proposed)

Fibromyalgia Evolution

Age Distribution of Fibromyalgia by Gender

Source: Mense S, Simons DG. Muscle Pain. Lippincott, William, & Wilkins; 2001.



FMS literature started soaring in the mid to late 80’s


ICD-9

1990 ACR Criteria for Diagnosis of FMS

1. History of Widespread Pain – defined as:

a) Pain on both sides of body

b) Pain above and below the waist

c) Axial skeletal pain is present

2. 11 of 18 Tender Points – defined as < 4 kg pressure:

a) Occiput

b) Lower cervicals (ant‐lat’l)

c) Trapezius

d) Supraspinatus

e) Second Rib (anterior)

f) Lat’l Epicondyle

g) Gluteal muscles

h) Greater Trochanter

i) Medial Knee



Mense S, Simons DG. Muscle Pain. Lippincott, Williams & Wilkins; 2001.

• Arbitrary locations

• Determined by consensus, not anatomy

The Original 18 Tender Point Locations

Pressure Algometer to Verify Tender Points < 4 kg




– Females generally have lower APT values than males

– If < 4 kg is set as “abnormal,” then statistics are skewed

– May this partially explain the 20:1 female‐to‐male ratio?

– May need 2 sets of APT criteria, one for each gender?

• Fibromyalgia is a painful, non‐articular condition…; it is the commonest cause of chronic, widespread musculoskeletal pain. It is typically associated with persistent fatigue, non‐refreshing sleep and generalized stiffness. Women are affected 10–20 times more than men.

• Fibromyalgia is often part of a wider syndrome encompassing: headaches, irritable bowel syndrome, irritable bladder, dysmenorrhea, cold sensitivity, Raynaud’s phenomenon, restless legs, atypical patterns of numbness and tingling, exercise intolerance and complaints of weakness.

• A varying proportion of fibromyalgia patients experience significant depression or anxiety which may contribute to the severity of symptoms or result from having chronic pain.

• Typically symptoms are worse during periods of cold or damp weather, at the beginning/end of the day and during periods of emotional stress.

1992 World Congress on Myofascial Pain and Fibromyalgia Syndrome convenes and publishes the Copenhagen Declaration:



Central Sensitivity Syndrome

Sarzi‐Puttini P et al. Chronic widespread pain: from peripheral to central evolution. Best Pract Res Clin Rhematol, 2011 Apr;25(2):133‐9

• Not overtly or systemically inflammatory

• Not autoimmune (as far as we can tell)

• Not a muscle disorder

• Not the same as Chronic Fatigue Syndrome (CFS)

Dispelling Some FM Myths



• Viral: EBV, CMV, HSV, HIV, Hep. C, Coxsackie, parvovirus, etc.• **Neurotransmitters:

– Serotonin and norepinephrine deficiency– Substance P excess – Alterations in nocturnal melatonin

• Hormones: Thyroid, adrenal, growth hormone• Sleep disorders• Psychological: Inability to cope with stressors

(post‐traumatic stress disorder, PTSD)• Neurological: Increased sympathetic drive to muscles, cervical compression• Nutritional: Mg, malic acid, B vitamins, Mn, Se• Metabolic:

– Mitochondrial dysfunction– Cumulative toxic load– Intestinal dysbiosis/”leaky gut”– Heavy metals (i.e., aluminum/mercury)

Proposed FMS Etiologies Through the Years *

*Many unsubstantiated by any significant evidence‐base*Fitzcharles MA et al. Fibromyalgia: evolving concepts over 2 decades, CMAJ, Sept. 17, 2013, 185(13)** Arnold LM. Biology & Therapies in Fibromyalgia, Arthr Res Ther, 2006; 8(212)

• History! – Subjective global tenderness/pain, assoc. S/Sx

• Examination– Objective global tenderness/pain

• Labs– Rule out other disease/disorder

FMS Diagnosis per ACR Criteria



No Fibromyalgia Factor Test!

• Chronic fatigue syndrome (CFS)• Myofascial pain syndrome (MPS)• Organic depression/anxiety• Multiple bursitis/tendonitis sites• Connective tissue disorders (SLE, RA, polymyalgia rheumatica, mixed

connective tissue disease) • Stealth infections: Lyme and co‐infections, viral• Endocrine myopathies (hypothyroid, adrenal, growth hormone)• Dysglycemia (insulin resistance/syndrome X)• Anemia• Multiple sclerosis• Occult malignancy• GI dysbiosis and toxicity• Etc.

FMS Differential Diagnosis



FM Pain Diagram

FMS and /or Somatization Disorder

Regional MyofascialPain Syndrome



Tender Points for Diagnosis of Fibromyalgia

Say Goodbye To Tender Points?

Wilke WS. New developments in the diagnosis of fibromyalgia syndrome: Say goodbye to tender points? Cleveland Clinic Journal of Medicine, Vol 6, No 6, June 2009



Drug Therapy:• Tricyclics (amitriptyline, clomipramine, dothiepin, etc.) • SSRIs (fluoxetine, citalopram, etc.)• MAOIs (moclobemide)• SSNRIs (duloxetine, venlafaxine, milnacipran, etc.)• Alpha‐2 delta ligands /Gabapentinoids (pregabalin, gabapentin)• GABA receptor agonists (Sodium oxybate /SXB)• Low Dose Naltrexone (LDN)• 5‐HT3 antagonists (ondansetron, tropisetron, etc.)• NMDA antagonists (tramadol, dextromethorphan, etc.)• Dopamine 3 agonists (pramipexole, etc.)• Cyclobenzaprine • NSAIDS• Acetaminophen • Lithium carbonate

FM Medical Management Over The Years

Arnold LM. Biology and therapy of fibromyalgia: new therapies in fibromyalgia. Arthritis Res Ther. 2006; 8:212.

(Current trends in therapy)

“Recent pharmacological treatment studies have focused on selective serotonin and norepinephrine reuptake inhibitors (SSNRIs), which enhance serotonin and norepinephrine neurotransmission in the descending pain pathways and lack many of the adverse side effects associated with tricyclic medications.”




Loggia M et al. Evidence for brain glial activation in chronic pain. Brain, 2015, Jan 12.



All can be associated with fatigue and muscle tenderness

Schneider M, Brady D, Perle S. J Manipulative Physiol Ther. 2006;29:493‐501.

Fibromyalgia Syndrome Clinical Reasoning Guide

“Classic” FMS‐ Sleep disorder

‐ Anxiety

‐ Depression

‐ Alterations of CNS chemistry

‐ Neuro‐endocrine imbalances

Organic‐ Anemia‐ Lyme disease‐ Hypothyroidism‐ Inflammatory arthritides

‐ Dysglycemia‐ Occult carcinoma‐ Multiple sclerosis

Functional‐Mitochodrialdysfunction

‐ Toxicity‐ GI dysbiosis‐ Nutritionaldeficiencies

Musculoskeletal‐ Multiple TrPs‐ Joint dysfunction‐ Muscle imbalance‐ Postural distortion‐ Undiagnosed disc/facet lesions

“Pseudo ‐ FMS”The various disorders

that are misdiagnosed as FMS

1) Organic diseases

2) Functional disorders

3) Musculoskeletal disorders



• Biopsy studies = No tissue specificity in FMS patients

• EMG studies = No specific changes in muscle tone

• Drug studies = No benefit of NSAIDs or steroids over placebo; but significant benefit of SSRI/SSNRIs

• Pain Studies = FMS patients feel “pain” at tender points at decreased thresholds when compared to “control” points.

All Over Their Bodies…

CONCLUSION = No peripheral soft tissue is the pain generator in FMS

What Exactly Are These Tender Areas/Points?

Borg‐Stein J, Stein J. Trigger points and tender points: one and the same? Rheum Dis Clin North Am. 1996 May;22(2):305‐22.


If No Soft Tissue is the Pain Generator in FMS, From Where is the Pain Coming?

Most likely the CNS!



The Muscle Pain Pathway: Spinothalamic Tract


NorepinephrineTricyclicsSSNRI

*Seems to havebenefit for limitedamount of time in about 25% of subjects




Alpha-2 delta ligandsGabapentinoids

*Burning Pain*Makes Sleepy

• The spinal cord can be viewed as a “peripheral brain”; it contains both grey and white matter.

• Interneurons within the dorsal horn integrate and modify all incoming sensory input.

• Grey matter of the spinal cord is capable of associative conditioning or “learning.”

• Complexity of the cord’s interneuronal connections allow for the phenomenon of referred pain to occur.

The Spinal Cord



Simplified Convergence‐Projection Theory of Referred Pain

Spread of Pain to Normal Tissues by Spillover of Substance P



Descending Antinociceptive System

Dysfunction of the DANS is now Thought to be the Major Cause of Classic FMS by the Major Researchers in the Field

Julien N, et al. Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition. Pain. 2005;114:295‐302.



Picture of Pain

A) Sensory Cortex

Discrete Pain Localization

B) Cingulate Cortex

Emotional‐Affective Pain

Bushnell CM, et al. Imaging pain in the brain. Journal of Musculoskeletal Pain. 2002;10 (1‐2): 59‐72.

A brain signature that identifies fibromyalgia sufferers with 93 percent accuracy has been discovered by researchers, a potential breakthrough for future clinical diagnosis and treatment of the highly prevalent condition.

An MRI image showing the multivariate brain pattern that predicts fibromyalgia status on the basis of brain activation during multisensory stimulation.

Marina López‐Solà, Choong‐Wan Woo, Jesus Pujol, Joan Deus, Ben J. Harrison, Jordi Monfort, Tor D. Wager. Towards a neurophysiological signature for fibromyalgia. PAIN, 2016; 1 DOI: 10.1097/j.pain.0000000000000707

Neural signature for fibromyalgia may aid diagnosis, treatment



Descending Antinociceptive SystemLimbic System

Hypo‐ThalamusPeriaqueductal

(PAG) Gray Matter

Nucleus Raphe (NRM) Magnus

Spinal Cord

SEROTONIN (5‐HT)

Limbic system: “emotional brain,” can block pain or facilitate pain

FMS patients may have significant psychological factors affecting the limbic system, which may dampen the DANS.



From: Hopper, A.-IFM-AIC Presentation 2017

Limbic System

1. Ascending Arousal System

‐ Hypervigilance, sleep disorders

3. DANS

‐ Inhibition of sensory stimuli

5. HPA Axis

- Increased cortisol, ACTH, adrenaline

4. Reticular Formation

‐ Increased skeletal muscle tone

2. Sympathetics & Parasympathetics

‐ “Irritable Everything”

Every Symptom of FMS!



Early adverse life events change the brain in a sex-dependent manner. Childhood traumas affect women much differently than men resulting in altered brain structure leading to psychological issues as an adult as well as a heightened response to pain. When working with female patients who have depression, anxiety, pain, autonomic/HPA axis dysfunction always take a thorough trauma history which will usually reveal a variety of physical and/or emotional traumas when they were young.



• Serotonin appears to be the key neurotransmitter involved in FMS and sleep

• 3 major functions:– Drives the hypothalamus/HPA axis

– Alters substance P levels and “pain”

– Initiates onset of deep stage 4 sleep

Serotonin, Sleep Disorders, and FM

PAIN

POORSLEEP

FATIGUE

STRESS



Sleep Dysfunction in FM

• Non‐restorative sleep is a major symptom of FM and correlates with the global achiness/TPI

• Typical EEG pattern of “alpha wave intrusion” during non‐REM delta wave sleep

• Most intense delta activity is in the frontal lobes of the cortex

• Frontal lobe hypoactivity during waking state is associated with inability to concentrate or focus attention (i.e., Fibro‐Fog).



At the end of the study, the amber lens group experienced significant (p < .001) improvement in sleep quality relative to the control group and positive affect (p = .005). Mood also improved significantly relative to controls.”



• In bed by 10pm, up by 7am consistently

• Limit bright/blue‐light and electronics 3 hrs. prior to bed

• Dark quiet bedroom with no pets

• No TV, reading or activities in bedroom (other than two!)

• Prayer and progressive relaxation 30 mins. prior to bed

Sleep Hygiene



Biofeedback

Heart Rate Variability



Biofeedback Made Simple at Home

• Decreased serum and platelet serotonin

• Increased substance P in CSF

• Decreased 5‐HIAA and TRP in CSF

• Decreased TRP levels in CSF, platelets, serum

Dadabhoy D, Clauw DJ. Fibromyalgia: different type of pain needing a different type of treatment. Nat Clin Pract Rheumatol. 2006;2:364-372.

Evidence of Serotonin Deficiency in FM



Biochemistry of Serotonin

TRP5‐HTP

5‐HT5‐HIAA

Excretion

MAO Inhibitors

Re‐uptake of 5‐HT by neurons

SSRIs/SSNRIs

Serotonin and Substance P

Brain 5‐HT Spinal Cord 5‐HT

Spinal Cord Substance P

Brain 5‐HT Spinal Cord 5‐HT

Spinal Cord Substance P

Descending Inhibitory System

FMS = Failure of Descending Inhibitory System?

(Normal)

(Abnormal)



• Serotonin Modulators– 5‐HTP, melatonin, etc.

– Antidepressant medications – Tricyclics, SSRIs, SSNRIs, MAOIs, etc.

• Stress & Anxiety Management Management– Biofeedback, guided imagery, prayer, meditation, yoga, adrenal

therapy, proper sleep, etc.

– GABA, L‐theanine, inositol, calming adaptogenic botanicals

• Nutritional Supplementation– Mg, malic acid, etc.

Classic FMS Treatment

Rossy L A, Buckelew S P, Dorr N, et al. A meta‐analysis of fibromyalgia treatment interventions. Ann Behav Med. 1999; 21:180‐191.

Sim J, Adams N. Systematic review of randomized controlled trials of non‐pharmacological interventions for fibromyalgia. Clin J Pain. 2002;18:324‐36.

In a randomized, placebo‐controlled study of 200 fibromyalgia patients who were also migraine sufferers, 5‐HTP (400 mg/d) was compared to a tricyclic drug (amitriptyline) and an MAOI (pargyline or phenelzine). The combination of 5‐HTP (200 mg/d) with an MAOI was also evaluated. Patients were treated for a total of 12 months and kept a daily pain dairy by means of a visual analog scale. At the end of the 12‐month trial period, all treatment regimens showed significant improvement over placebo (p < 0.0001), although the combination of 5‐HTP with the MAOI was the most effective. 5‐HTP alone was as effective as the tricyclic or MAOI drugs. No patients withdrew from the study due to side effects; 8% of patients taking 5‐HTP alone reported some degree of stomach upset.

Treatment with 5‐HTP in FMS

Nicolodi M, Sicuteri F. Fibromyalgia and migraine, two faces of the same mechanism. Serotonin as the common clue for pathogenesis and therapy. Adv Exp Med Biol. 1996;398:373‐379.



Neurotransmitter Metabolism

If elevated, ask:1. 5‐HTP or L‐Tryptophan

supplements?2. SSRI’s? MAOI’s?

If low, ask:1. Hx depression?2. Insomnia?

• 5‐HTP: 150–300 mg qd in divided dosages with last dose one hour before bed

and/or

• Melatonin: 3–9 mg qd one hour before bed (Sustained‐release preferred)

Simplified Nutraceutical Modulation of Neurotransmitters in Classic FM



Sceletium tortuosum

• The South African plant Sceletium tortuosum has been used by the indigenous people for hundreds of years for: Relaxation, Stress, Thirst and Hunger (before long hunting trips), soothing infants from: Colic and teething. Modern science has proven its benefits in: increasing mood state, cognitive function, reducing stress, inducing a calm but not sedative effect. It appears to achieve this by a dual inhibition action, by acting both as an SSRI and by its inhibitory effects on PDE4 (phosphodiesterase 4). PDE4 inhibitors are known to possess procognitive (including long‐term memory‐improving), wakefulness‐promoting,] neuroprotective, and anti‐inflammatory effects It has been shown in the research to be non‐addictive, as well as showing no dependency or withdrawal symptoms, after 3 months of continuous use.

Terburg D, Syal S, Rosenberger LA, et al. Acute Effects of Sceletium tortuosum (Zembrin), a Dual 5‐HT Reuptake and PDE4 Inhibitor, in the Human Amygdala and its Connection to the Hypothalamus. Neuropsychopharmacology. 2013;38(13):2708‐2716.



diagnosticsolutionslab.com

Neurotransmitter Metabolism

High levels:1. Heightened sympathetic reactions in

response to stress2. Neuroblastic Tumor (extreme elevations

in VMA)3. Indication for Adrenal Support

Phenylalanine Tyrosine

Dopamine

Norepinephrine

Epinephrine

Vanilmandelate

Homovanillate

Neurotransmitter Biosynthesis Compound in Urine



“Patients with posttraumatic stress disorder (PTSD) have decreased cortisol and increased catecholamine secretion.”

Sympathetic Compensation

Baker DG, et al. Plasma and cerebrospinal fluid interleukin‐6 concentrations in posttraumatic stress disorder [abstract].

Neuroimmunomodulation. 2001;9:209‐217.

This phenomenon can occur in those who may not meet the diagnosticcriteria of PTSD, but also those with “Distressing Life Events.” (See work of Peter Mol, et al)

Is a Sustained Fight/Flight State One Mechanism Behind FM?

Netter FH. The CIBA Collection of Medical Illustrations. Volume 1: The Nervous System. 1977.



Dopamine Melatonin



Calming Adrenal Botanicals

Ashwagandha(Withania somnifera)15% withanolides

100–200 mg

German chamomile(Matricaria recutita)1.2% apigenin

100‐200 mg

Valerian root(Valeriana officinalis)

100–200 mg

Passion flower(Passiflora incarnate)

100–200 mg

Lemon balm (Melissa officinalis)

100–200 mg

1. Archana R, Namasivayam A. Antistressor effect of Withania somnifera. J of Ethnopharmacol 1999; 64(1): 91-32. Kennedy DO et al. Attenuation of laboratory-induced stress in humans after acute administration of Melissa officinalis (Lemon Balm).

Psychosomatic Med. 2004;68(4):607-613.3. Groff JL, Gropper SS. Advanced Human Nutrition and Human Metabolism (3rd ed.). Belmont, CA: Wadsworth: 2000

Calming Adrenal Nutrients

L-theanine 100–200 mg

L-taurine 100–200 mg

Phosphatidylserine 50–100 mg

GABA 100 mg

Magnesium-L-threonate 150 mg

Vitamin C (ascorbic acid) 500 mg

Thiamine (B1) 50 mg

Riboflavin (B2) (riboflavin-5-phosphate) 10 mg

Pantothenic acid (vitamin B5) 250 mg

Pyridoxal 5’-phosphate (coenzyme B6) 10 mg

Folate (5-MTHF) 500 mcg

B12 (methyl, hyroxy, adenosyl-cobalamin) 2 mg

1. Hellhammer J et al. Effect of soy lecithin phosphatidic acid and phosphatidylserine complex (PAS) on the endocrine and psychological responses to mental stress. Stress:The International Journal on the Biology of Stress. 2004;7(2):119-126.

2. Frosini M et al. Interactions of taurine and structurally related analogues with the GABAergic system and taurine binding sites of rabbit brain. Br J Pharmacol. 2003;138:1163-1171.

3. Driskell JA. Vitamin B6 requirements of humans. Nutr Res 1994; 14: 293-324.4. Groff JL, Gropper SS. Advanced Human Nutrition and Human Metabolism (3rd ed.). Belmont, CA: Wadsworth: 2000



• Stress management techniques

• Counseling / Therapy

• Promote proper sleep and circadian rhythm

Additional Intervention

Ablin J et al. Treatment of fibromyalgia syndrome: recommendations of recent evidence-based interdisciplinary guidelines with special emphasis on complementary and alternative therapies. Evid Based Complementary AlternatMed, 2013; 485272.



Patients with Widespread Pain and Fatigue

Classic FMS Metabolic-Functional

Medical-Pathologic

Musculo-Skeletal

Differential Diagnosis into Subsets

Complete medical exam and management of the pathology that is causing the pain and fatigue.

• Exam to determine the NMS pain generator(s).

• Chiropractic manual techniques, massage, rehab, modalities, etc.

• Ortho, neuro, or physical medicine referral.

• Limbic system over-activity.

• Sleep disorder must be treated.

• Anxiety, depression, PTSD?

• Psychotropic meds may be needed per MD.

• Cog Behav Therapy, Biofeedback

• Exam to find what metabolic dysfunction is causing the pain and fatigue.

• Vitamin or enzyme deficiency?

• Functional hormone imbalance?

• Food allergies, GI dysbiosis, toxicity, meds?

Schneider M, Brady D, Perle S. J Manipulative Physiol Ther. 2006;29:493-501.

The Great FMS Masqueraders/Imposters

1. Sub‐optimal thyroid function

2. Myofascial pain syndrome

3. Sub‐optimal mitochondrial/Energy metabolism

*Based on my opinion from clinical experience and discussion with colleaguesWho also manage a large number of patients presenting with the FMS label.



Hypothalamus TRH Pituitary

TSH

Thyroid Gland

5% T3

95% T4Liver or

Kidney

rT3

Inactive

(45%)

T3

Active

(35%)

5’‐deiodinase

(Se)

5‐deiodinase

Cell

Nucleus

~ 95%



Elongated sarcomeres TrP nodule = focus of contracted sarcomeres

Normal sarcomeres



Therapeutic Nutritional and Herbal Strategy for Muscle Spasm

• Magnesium: 100 mg q4h

• Calcium: 50 mg q4h

• Valerian root: 100 mg q4h

• Passion flower: 200 mg q4h

• Hops: 100 mg q4h

• Kava: 100 mg q4h

Lipoic Acid, CoQ10?

H

H

Both High?



Energy

Energy

Energy

Energy

All Elevated?

SevereCoQ10

Deficiency

L‐Carnitine Markers



• CoQ10: 100‐200 mg bid

• L‐Carnitine: 2.5 gm bid

• D‐Ribose: 2 gm bid

• B‐Complex

• Lipoic Acid: 200 mg qd

• NADH/Nicotinamide riboside: 125 mg qd

• Quality multivitamin‐mineral

• PQQ : 20 mg bid

• Botanicals for mitochondrial biogenesis– Rhodiola, Curcumin, Resveratrol, Green tea, etc.

Mitochondrial Support

Neurological

Oaklander AL, Herzog ZD, Downs H, Klein MM. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain. 2013 Jun 5.



Small Fiber Polyneuropathy

Review



All can be associated with fatigue and muscle tenderness

Schneider M, Brady D, Perle S. J Manipulative Physiol Ther. 2006;29:493‐501.

Fibromyalgia Syndrome Clinical Reasoning Guide

“Classic” FMS‐ Sleep disorder

‐ Anxiety

‐ Depression

‐ Alterations of CNS chemistry

‐ Neuro‐endocrine imbalances

Organic‐ Anemia‐ Lyme disease‐ Hypothyroidism‐ Inflammatory arthritides

‐ Dysglycemia‐ Occult carcinoma‐ Multiple sclerosis

Functional‐Mitochodrialdysfunction

‐ Toxicity‐ GI dysbiosis‐ Nutritionaldeficiencies

Musculoskeletal‐ Multiple TrPs‐ Joint dysfunction‐ Muscle imbalance‐ Postural distortion‐ Undiagnosed disc/facet lesions

“Pseudo ‐ FMS”The various disorders

that are misdiagnosed as FMS

1) Organic diseases

2) Functional disorders

3) Musculoskeletal disorders



Schneider M, Brady DM., Perle SM Differential Diagnosis of Fibromyalgia Syndrome: Proposal of a Model and Algorithm for Patients with the Primary

Symptom of Chronic Widespread Pain. JMPT, 2006;29:493‐501



Patient presents with Sx of widespread pain

& fatigue

Is pain pattern truly the “widespread

pain” of FMS

Is there frank joint swelling? Does this “regional

pain” indicate a musculoskeletal

referred pain pattern?

Lab tests to rule out arthritides:• Lyme Disease

• RA• Lupus, Gout, Ank Spond, etc.

Tests positive?

Box 1Full physical exam, medical

history, and blood/urine tests:

Tests positive?

Does patient exhibit all aspects of

Classic FMS?^^See Note1

^^Note 1: Classic FMS1. True widespread allodynia or hyperalgesia .2. Significant sleep disorder.3. History of significant anxiety/depression/PTSD.4. Fatigue/ neuroendocrine disorders.

Screen for functional and metabolic disorders

***See Note2

Strong likelihood for Classic FMS. Patient needs a team approach:

***See Note2

Suspicion of visceral referred pain requires

complete medical evaluation.Go to Box 1

Musculoskeletal disorders: Determine pain generator(s) and render

appropriate treatment.***See Note2

Patient may have pathology or disease that requires medical

management***See Note2

No

Yes No

No

No

Yes Yes

YesNo

Yes No

***Note 2: Overlapping Disorders1. Having one disorder does not mutually exclude other

disorders, as patients may have an overlap between disorders.

2. Many patients with psychological illnesses and internal disorders have poor nutrition and would benefit from metabolic therapies.

3. Many patients with psychological illnesses have concurrent myofascial trigger points that would benefit from soft tissue therapies.

Yes

Schneider M, Brady D, Perle S. J Manipulative Physiol Ther. 2006;29:493-501.



Available NOW at:

The Fibro Fix Summit

LEAR MORE andget bonus materials at:

FibroFix.com

DrDavidBrady.com

Access the Summit at:

FibroFixSummit.com

Released July 12, 2016!

#1 Amazon Bestseller in five categories

College of Naturopathic Medicine

College of Chiropractic

Human Nutrition Institute

Acupuncture Institute

Physician Assistant Institute

FONES School of Dental Hygiene

School of Nursing

Doctorate of Health Sciences (New in 2016)

Visit: Bridgeport.edu

Univ. of Bridgeport-Division of Health Sciences



Fully accredited Master’s degree in interventional human nutrition from a functional medicine perspective

Available in convenient interactive on‐line or weekend‐only on‐campus formats

Qualifies to sit for CNS, CCN, DACBN examiations

Generous advanced standing transfer credits offered for physicians (i.e., MD, ND, DO, DC, DDS, etc.)

Visit: Bridgeport.edu/nutrition

UB Human Nutrition Institute

“Dr. Brady, may I be excused? My brain is full.”

Fibromyalgia and Global Pain Syndromes · Fibromyalgia and Global Pain Syndromes Central...

Documents

Transcript of Fibromyalgia and Global Pain Syndromes · Fibromyalgia and Global Pain Syndromes Central...