From: Kenneth Orbeck, D.O.
Sent: Tuesday, June 12, 2012 10:42 AM
To: Kenneth Orbeck, D.O.
Fibromyalgia is a chronic condition diagnosed by exclusion. It is characterized by widespread musculoskeletal pain, hypersensitivity to various stimuli, and often involves sleep disturbances and elements of fatigue. Other common symptoms with fibromyalgia include frequent headaches, difficulty with concentration and memory, underlying anxiety and elements of panic disorder, irritable bowel syndrome, and menstrual pain or irregularities. Fibromyalgia is a frequently diagnosed condition and places significant financial burdens on the individual as well as society as a whole. There are significant healthcare costs associated with the treatment of fibromyalgia as well as significant loss in both productivity and frequent disability. Conventional therapy has not shown an optimal response in a high proportion of cases which involves treatment such as analgesic therapy, antidepressants, trigger point injections, and psychological counseling and stress management.
Let’s now take a look at fibromyalgia from a functional medical standpoint involving possible metabolic derangements and underlying secondary inflammation. Fibromyalgia appears to be an intracellular energy deficient state often involving poor mitochondrial function to produce the proper energy pathways required for health and vitality. In order for the human body to have adequate energy and metabolic function, adequate nutritional intake and absorption must occur; with transport of these micronutrients into the cell, and utilization of these nutrients through the KREBBS cycle to generate adequate energy while eliminating toxic waste. Cellular communication is important which involves both neurotransmitters and hormonal balance. Toxicology issues are also important which can have a negative effect on secondary enzymatic pathways necessary to allow for tissue regeneration and required end products. Before we look at functional and metabolic treatment protocols, we must discuss the necessary evaluation of any individual presenting with signs and symptoms consistent with fibromyalgia. Examining the following physiologic parameters will guide the practitioner to provide a more concise treatment approach which often results in an optimal outcome and reduction of symptoms. Categories that I often look at include detoxification and biotransformation issues, immune imbalance and inflammation, oxidative and reduction hemodynamics, intestinal digestion and absorption, hormonal and neurotransmitter balance, and mitochondrial structure and membrane integrity. Any and all of these factors will have a cause and effect relationship to chronic inflammation.
Toxicology issues are always important when there are issues of inflammation and in patients that present with symptoms consistent with fibromyalgia. The environmental toxic load continues to rise in the food that we eat, the water we drink, and the air that we breathe. As our toxic burden increases, the body will often reach a level of excess which places a burden on the liver and detoxification pathways allowing the body continual build up of these various toxins. This will have a negative effect upon metabolic pathways and the ability to maintain health. Intestinal health is important to rid the body of toxic waste. Liver health is extremely important which involves phase 1 and phase 2 detoxification pathways allowing the body to transform toxic substances into non-toxic byproducts which then can be excreted through the bowel or kidney. Intracellular toxicology issues are extremely important as they have a direct effect on cellular membrane, mitochondrial transport and function, and issues of energy production. Testing is often required to include environmental toxin testing, toxic metal analysis, and organic phosphates. Detoxification protocols begin with intestinal support and proper bowel function, hepatic detoxification of the liver utilizing multiple nutrients and dietary changes as well as adequate hydration, and cellular detoxification involving both nutrients and chelation if toxic metals are identified.
Immune disorders and immune imbalance are also important in individuals who present with symptoms of fibromyalgia. Frequently in chronic inflammatory states, TH1 cellular immunity becomes excessive over TH2 humoral immunity. Humoral immunity is responsible for underlying allergies such as seasonal allergies, or food allergies, especially to dairy. TH2 immunity involves B cells responsible for antibody formation. TH1 or cellular mediated immunity is involved in the delayed hypersensitivity reactions and is responsible for protection against underlying viruses and bacteria. This involves the activation of natural killer cells as well as the production of macrophages. When cellular mediated immunity is excessive, a possible outcome may result in autoimmune diseases. Multiple nutritional products are useful in balancing TH1/ TH2 immune dysregulation. One common product that I often utilized is bioactive proteins through the use of colostrum. Proline rich polypeptides (PRP’s) are tiny carrying proteins that contain abundant information with amazing abilities to balance the immune system. During times of intense physical stress, they enhance the production of cytokines through immune activation. When the situation is opposite and the immune system is healthy, they react to environmental factors and send signals to specific cell receptors to decrease cytokine formation and balance the immune system.
Oxidative and reduction hemodynamics is also important when dealing with chronic inflammatory states and fibromyalgia. Oxidative stress on the body can come from multiple substances, but the most common are environmental toxins and toxic metals. Oxidative stress forms what is known as reactive oxygen species (ROS) which play a role in developing free radicals which can lower metabolic enzymatic activity. These species have been shown to increase sympathetic tone as well as plasma norepinephrine often resulting in an excitatory neurological state and may play a role in pain modulation. Functional testing of the serum and urine can allow the practitioner evidence of toxicity which needs to be removed before biotransformation can be successful. Utilizing several inflammatory markers such as TNF alpha, interleukin 1, interleukin 6, C-reactive protein, and homocysteine will aid in oxidative stress management. When these markers are elevated, the end result is often immune-exitotoxicity. This has an effect on our brain function. Neurotoxicity and brain damage are often the result of this process and is commonly linked to toxic metal stress.
Intestinal health (the function of digestion and absorption) is critical in the management of chronic disease states and fibromyalgia. The ability of our body to properly digest nutrients and transport them across the mucosa into the bloodstream where they can be utilized for cellular energy is vitally important. Issues here involve the proper amount of acid in the stomach to begin digestion, adequate pancreatic enzymes for the breakdown of protein and fats, and proper mucosal integrity to allow for transportation of nutrients. Interference can occur here with underlying pathogens such as yeast, parasites, or non-friendly bacteria. Identifying any pathological burden within the gut must be evaluated and removed to allow for proper nutrient absorption. The mucosal integrity is vitally important as there is only one cell layer separating intestinal toxins from our blood stream. When a break in this layer occurs it results in issues of permeability it is often called “leaky gut”. Functional testing will allow the practitioner to identify issues of intestinal integrity and begin the repair process where needed so adequate nutrition will be available to cells and metabolic pathways.
Mitochondrial function is very important in the treatment and assessment of fibromyalgia. Membrane integrity and mitochondrial function allow for adequate energy production when proper nutrients are available. Utilizing functional testing and blood work will allow the detection of mitochondrial breakdown. Specific areas of breakdown may be secondary, for example, to specific nutritional deficiencies. Identifying these areas will allow the practitioner to replace specific nutritional needs allowing for energy production to occur within the cell. Since fibromyalgia may involve an energy deficient state within the cell, maximizing energy production remains critical. Some products that have been utilized with success include deoxyribose, L-carnitine, magnesium, and coenzyme Q 10.
Hormonal and neurotransmitter balance is vitally important in the treatment of chronic inflammatory disease including fibromyalgia. Neurotransmitters allow the brain to communicate to the body necessary functions within the endocrine system. Hormones act as cell regulators and allow cell to cell communication. Hormones have a direct influence on genetic cellular communication. This neural – hormonal mechanism allows the brain to influence the body in repair, regeneration, and the maintenance of optimal health. Bio identical hormone replacement therapy has been utilized in my practice with great success to optimize this communication allowing the body’s natural healing process to occur.
After looking at the above issues to identify any breakdown in the metabolic pathways regarding chronic disease and inflammation, treatment considerations are reviewed for optimal outcome. Dietary factors are important in the management of fibromyalgia. Emphasizing proper nutrition avoiding refined sugar and processed food is critical. Eliminating caffeine, alcohol, and food additives is also necessary. Cooking methods are also important, as cooking foods quickly on intense heat can develop advanced glycation end products (AGE’s). These products result from the interaction of the reduced sugar and the protein. This modified type of protein has been shown to evoke an inflammatory response. Studies have shown that when cooking at lower temperatures and in the presence of water, AGE formation will be significantly reduced. Patients should be made aware of any underlying food allergies and eliminate these foods from their diet. Considering a raw food vegan diet is important as studies have shown that consumption of an uncooked vegan diet for three months improve symptoms of fibromyalgia.
Nutritional supplementation is also important in the management of fibromyalgia and chronic disease. Magnesium deficiency is often found in patients with fibromyalgia and magnesium supplementation can be beneficial. Intravenous supplementation of magnesium has been shown to improve myalgias within 48 hours. Intravenous nutrient therapy has often been reported to improve the symptoms of fibromyalgia. SAMe administration has been shown to improve symptoms of fibromyalgia through double-blind trials. Oral administration of SAMe seems to be the preferred route of delivery. 5-HTP is a precursor to serotonin. There are suggestions that serotonin deficiency is involved in fibromyalgia pathogenesis. Since 5-HTP and antidepressants both affect serotonin, 5-HTP should be avoided or used in caution with low doses on patient’s taking antidepressants. Vitamin D has been shown to improve symptoms of fibromyalgia. Musculoskeletal pain is one of the manifestations of vitamin D deficiency. Although the relationship between vitamin D and fibromyalgia is uncertain, vitamin D deficiency should be evaluated and supplemented appropriately where indicated. As discussed above, fibromyalgia is often intracellular energy deficient state. Acetyl-L-carnitine is a good source of l-carnitine which plays a role in mitochondrial energy production. It serves to help transport fatty acids across the mitochondrial membrane. Ribose has also been shown to enhance mitochondrial function. Ribose acts as a key component in the synthesis of ATP.
Certainly fibromyalgia is a complicated disease state which may be secondary to multiple metabolic derangements. Through careful assessment and utilizing functional testing as listed above, appropriate protocols and treatment programs can be initiated with greater success. This disease is often chronic and becomes very frustrating to the patient. Psychological components must be assessed and the possibility of body- mind syndrome must be identified. Carefully identifying any toxicology issues and removing them, assessing bowel health and integrity for nutrient absorption, supplying the body proper nutrition, and enhancing the body’s communication through both hormonal and neurotransmitter balance will result in greater success and optimal outcomes in the management of fibromyalgia.
Kenneth Orbeck DO
ABAARM Board Certified
Fellowship Trained Anti-Aging Medical Specialist
BodyLogicMD of Greenville
300 Executive Center Drive, Suite 200
Greenville, SC 29615
Tel: (877) 341-7407
Fax: (864) 284-6774
Blogg @ www.drkennethorbeck.com
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