– A Complementary and Alternative Medicine (CAM) Approach
Complementary and Alternative Medicine (CAM) is defined by the National Institutes of Health (NIH) Center for Complementary and Alternative Medicine as, “those treatments and healthcare practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies.”
At this point in time, conventional medicine has limited offerings to patients suffering from fibromyalgia (FM). Sadly, there are still practicing physicians who don’t even believe that fibromyalgia is “real.” For more information regarding conventional assessment and management of FM, see: Fibromyalgia.
While one focus of conventional treatment for FM is on exercise, many FM patients do not tolerate or benefit much from exercise due to their underlying FM and associated central sensitivity or due to other co-morbid pain conditions. That being said, exercise within tolerable limits is still encouraged with special emphasis on low-impact exercise such as swimming or other water-based exercise and yoga or tai chi as directed by an instructor with sensitivity to the physical limitations of their student.
See: yoga or tai chi
With FM as with all forms of chronic pain, conventional medicine turns to non-conventional mind-based activities to improve patient skills with coping techniques for adapting to, and living with, chronic pain. These techniques include cognitive behavior training (CBT), meditation and other “mindful” exercises that guide the practicioner to focusing their minds on singular activities that relax and de-stress the patient. See: CBT, meditation
Another very useful treatment option is hypnosis, which is in effect a guided mindful technique, one with particular effectiveness in FM.
However, many patients continue to fail to achieve adequate relief of their FM symptoms despite conventional medications, exercise and mindful exercises. These symptoms can be broadly categorized into 3 arenas:
- Fatigue including non-restful sleep
- Cognitive impairment or “brain fog”
To address these concerns, there are some CAM treatments that can be considered, see below.
For further understanding of FM, see:
Key to Links:
Grey text – handout
Red text – another page on this website
Blue text – Journal publication
CAM Treatment of Fibromyalgia Syndrome (FM)
For more information about the characteristic symptoms and features of FM, including conventional assessment and management,
Conventional management of FM focuses on the use of prescription medications including neuromodulating drugs such as anticonvulants and antidepressants and in some cases, opioids, although most conventional opioids offer limited analgesic benefit for FM pain. Conventional clinical management of FM is now turning also to behavioral approaches including exercise, cognitive behavior therapy (CBT), and a variety of ‘mindful’ exercises including meditation, yoga and tai chi. Unfortunately the conventional medical community offers little, if any, access to these treatment options and commercial insurers are unlikely to pay for them.
CAM Treatment of FM – Pain
Most opioid analgesics offer limited benefit for FM pain and the anticonvulants and antidepressants are also of limited benefit and often not tolerated well due to side effects. As alternatives to these medications, CAM medications provide some helpful options for managing FM pain.
CAM Treatment and Exercise
While exercise for FM pain is beneficial for some and intolerable for others, there are some CAM alternatives that may improve the effectivenss and tolerability of exercise for FM pain. Recent research indicates that the pathophysiology of FM pain is related to oxidative stress and mitochondrial dysfunction (please read about mitochondrial dysfunction). It is known that exercise activates SIRT1 which in turn stimulates mitochondrial biogenesis resulting in mitochondrial repair and improved function. However, it is also known that activating SIRT1 is not likely to benefit in the absence of adequate amounts of NAD+. Therefore, treatments that supplement SIRT1 activity (NRF2 activators) and increase NAD+ such as Nicotinamide Riboside (NR) are likely to have a synergistic effect on the benefit of exercise on FM pain.
Caloric Restriction and Fasting
There is a growing amount of research that indicates that restricting calorie intake below the individual’s daily needs and fasting provide potential benefit for improving mitochondrial function and this benefit has been noted in patients with fibromyalgia.
Antioxidants and NRF2 Activators
Oxidative stress and free radicals (ROS and RNS) have been found to play a role in the pain of FM, as related to mitochondrial dysfunction but also with the process of central sensitization. Studies indicate that antioxidants and NRF2 activators may reduce FM pain.
Palmitoylethanolamide (PEA) is emerging as a new agent in the treatment of pain and inflammation with studies showing improved pain with FM. PEA appears to interact with glial cells and mast cells in the central nervous system as their mechanism of action in reducing nerve and inflammatory pain. It is also believed that glial cells play a role in central sensitization and PEA may be an effective treatment option for manifestations of central sensitivity in FM.
Treatment of pain in fibromyalgia patients with melatonin has been tested in a limited number of studies. In one study carried out on 21 female patients, melatonin was administered in doses of 3 mg for 4 weeks, 30 minutes before bed time. Improvements with respect to pain, fatigue and depressive symptoms were noted. Another study looked at 10 mg night time dosing with signficant improvement of fibromyalgia pain.
A recent 2013 publication on the use of ginseng (Panax ginseng) at a dose of 100mg/day in fibromyalgia found it to be effective for pain, sleep and fatigue. It was also helpful for anxiety, although amitriptylene was somewhat more effective than the ginseng but took longer (6 weeks) for the benefits to begin.
Ginseng’s antinociceptive effects have been demonstrated in preclinical studies. The mechanism by which the active agents (ginsenosides) in ginseng work may be the same as gabapentin (Neurontin) and pregabalin (Lyrcica), by inhibiting calcium channels in nerves in dorsal spinal cord, thus suggesting a potential synergistic benefit when taken with either of these medications. The inhibitory effects of ginsenosides on substance P-induced pain has also been confirmed.
Naloxone and Naltrexone
Recent research suggests that the opioid blockers, naltrexone and naloxone, may have clinical benefit for fibromyalgia. While not yet frequently used, they are well tolerated and there is growing evidence suggesting the benefit of naltrexone in fibromyalgia particularly when associated with hyperalgesia and central sensitization. Because they are opioid blockers, they cannot be used at the same time as opioids and should be started prior to initiating opioid therapy for a FM patient.
CAM Treatment of FM – Fatigue, Insomnia and Non-Restful Sleep
As noted above, recent research has indicated that the underlying pathophysiology of FM points to issues of oxidative stress and mitochondrial dysfunction. The mitchondria are components within the cell that contribute to energy production and the manufacture of antioxidants and it is believed dysfunction here leads to the fatigue, non-restful sleep and many other symptoms associated with FM.
In addition to the potential benefits of PEA, nicotinamide riboside (NR) and NRF2 activators (see above) for fatigue, additional supplements have been identifed as helpful for fatigue and sleep.
Coenzyme Q10 (CoQ10) is an antioxidant noted to have high levels in healthy mitochonria that is critical in mitochondrial function. CoQ10 levels (as measured in blood mononuclear cells) have been noted to be low in FM patients and treatment with CoQ10 has been found to improve multiple symptoms of FM.
Melatonin has multiple studies supporting the use of melatonin for the treatment of the pain, fatigue and insomnia related to fibromyalgia. Research suggests that it may require higher doses, up to 10 mg/day, to achieve the most benefits from melatonin.
Please review the following CAM treatment options that are believed helpful with the fatigue and insomnia associated with FM:
CAM Treatment of FM – Cognitive Impairment (“Brain Fog”)
Brain “fog” is a collection of symptoms that include reduced or inability to concentrate and multitask, as well as impaired short and long term memory. Like most of the FM symptoms described above, the cognitive impairment of FM is believed to be related to mitochondrial dysfunction and may respond to the treatments outlined above for the pain and fatigue of FM. A recent study published in 2014 pioneered a new application of a safe, established medication, memantine (Namenda), used for a variety of neurodegenerative disorders and now found to be beneficial in the cognitive impairment of fibromyalgia (see Fibromyalgia, NMDA antagonists).
Recent research implicates dysfunction of mast cells and glial cells as contributors to “brain fog.” Mast cells are found throughout the body and brain, adjacent to blood vessels, which contain histamine and various inflammatory substances that upon release into surrounding tissues lead to inflammation. In the case of mast cells in the brain and nervous system, their dysfunction can lead to impairment of the blood-brain barrier and activation of glial cells that stimulate neuroinflammation and dysfunction in the nervous system thought to contribute to the cognitive impairment typical of FM and other diseases.
A study published in 2015 suggests the potential benefit of luteolin, a potent antioxidant with anti-inflammatory and anti-cancer properties found in fruits and vegetables that is reported to stabilize mast cells, may be effective in the treatment of cognitive impairment. Unfortunately, luteolin is not well absorbed, or bioavailable, when ingested from food sources. A luteolin supplement formulated with olive oil was found to increase intestinal absorption. Also possibly noteworthy is that Luteolin appears to be metabolized by COMT so there may be genetically variant responses to Luteolin as well as possible drug interactions if taken with COMT inhibitors (green tea, quercetin and various prescription medications used in the treatment of Parkinson’s Disease.
Alpha lipoic acid (ALA), a mitochondrial nutrient, offers protective effects and possible improvements in age-associated cognitive and mitochondrial dysfunction of the brain. ALA improves age-associated decline of memory, improves mitochondrial structure and function, inhibits age-associated increase of oxidative damage, elevates the levels of antioxidants, and restores the activity of key enzymes. In addition, co-administration of ALA with other mitochondrial nutrients, such as acetyl-L-carnitine and coenzyme Q10, appears more effective in improving cognitive dysfunction and reducing oxidative mitochondrial dysfunction.
Bacopa monnieri, (also known as brahmi, water hyssop, Bacopa monniera, and Herpestis monniera), is an herb native to Australia and India that has been used for 1400 years in Ayurvedic medicine, prescribed for cognitive dysfunction to sharpen intellect and improve memory. However, the study of Bacopa monnieri is in it’s infancey in western medicine and there does not appear to be any studies that look directly at Bacopa for cognitive impairment associated specifically with fibromyalgia. There is evidence for Bacopa effectiveness in improving cognitive function but most of the evidence is still weak and concentrated on animal studies.
Bacopa appears to be safe and well tolerated at usual recommended doses but no specific recommendations for Bacopa in fibromyalgia can be advised at this time.
(For more information, see: Bacopa).
Citicoline is a natural food supplement that has been evaluated for treatment of the cognitive impairment and memory dysfunction associated with aging and several neurodegenerative conditions such as Alzheimer’s disease, Parkinson’s disease and traumatic brain injury. While there is evidence for citicoline effectiveness in improving cognitive function in these conditions, most of the evidence is still weak and concentrated on animal studies. Furthermore, there are no studies evaluating the benefits of citicoline in fibromyalgia.
Citicoline appears to be safe and well tolerated at usual recommended doses but no specific recommendations for Citicoline in fibromyalgia can be advised at this time.
(For more information, see: Citicoline).
CAM Treatment of FM – Music Therapy
Numerous recent studies have provided evidence that listening to music reduces perception of pain intensity and/or perception of control over pain and reduces stress, a contributor to pain. In recent studies looking at music and pain in fibromyalgia patients, listening to music provided many benefits with respect to pain, sleep and improvement of activities.
For more information, see: Music Therapy
CAM, FMS – Overview
- Fibromyalgia – Diet & CAM Summary
- Fibromyalgia and nutrition – what news? – 2015
- Nutrition and Supplements for Fibromyalgia
CAM, FMS – CBT
- CBT, Exercise May Ease Chronic Pain – in Clinical Context, Fibromyalgia
- Psychotherapy for patients with fibromyalgia syndrome. Systematic review, meta-analysis and guidelines. – PubMed – NCBI – 2012
CAM, FMS – Mindful Exercise, Meditation
- Mindfulness exercises
- Forever Young(er) – potential age-defying effects of long-term meditation on gray matter atrophy – 2015
CAM, FMS – Music Therapy
- Music as a sleep aid in fibromyalgia – 2014
- The effects of music listening on pain and stress in the daily life of patients with fibromyalgia syndrome – 2015
- The neurochemistry of music. – PubMed – NCBI
- Predictions and the brain: how musical sounds become rewarding. – PubMed – NCBI
- Effects of music on pain in patients with fibromyalgia. – PubMed – NCBI
- Music listening as a means of stress reduction in daily life. – PubMed – NCBI
- The impact of acute stress on hormones and cytokines and how their recovery is affected by music-evoked positive mood – 2016
- Stress exacerbates pain in the everyday lives of women with fibromyalgia syndrome–The role of cortisol and alpha-amylase. – PubMed – NCBI
CAM, FMS – Spa Therapy
CAM, FMS – Diet
- 5 Ways To Control Fibromyalgia With Diet – 2013
- Fibromyalgia and nutrition, what do we know? – PubMed – NCBI – 2010
CAM, FMS, Diet – Aspartame & MSG (glutamate)
- Aspartame-induced fibromyalgia, an unusual but curable cause of chronic pain. – PubMed – NCBI
- Relief of Fibromyalgia Symptoms Following Discontinuation of Dietary Excitotoxins – 2000
- Hidden Sources Of MSG And Aspartame In Foods
CAM, FMS, Diet – Gluten & Celiac Disease
- Clinical impact of a gluten-free diet on health-related quality of life in seven fibromyalgia syndrome patients with associated celiac disease
CAM, FMS – Genetics
CAM, FMS – Genetics: COMT
CAM, FMS – Genetics: COMT Inhibitors
CAM, FMS – Genetics, COMT Inhibitors: Quercetin
- Phytochemicals Inhibit Catechol-O-Methyltransferase Activity in Cytosolic Fractions from Healthy Human Mammary Tissues – Implications for Catechol Estrogen-Induced DNA Damage – 2004
CAM, FMS – Genetics, COMT Inhibitors: Green Tea
- Quercetin increased bioavailability and decreased methylation of green tea polyphenols in vitro and in vivo
CAM, FMS – Oxidative Stress
(See also: Antioxidants and NRF2 Activators)
- Oxidative Stress in Fibromyalgia – Pathophysiology and Clinical Implications – 2011
- Oxidative Stress in Fibromyalgia and its Relationship to Symptoms – 2009
- Clinical Symptoms in Fibromyalgia Are Better Associated to Lipid Peroxidation Levels in Blood Mononuclear Cells Rather than in Plasma
CAM, FMS – Mitochondrial Dysfunction
(See also: Antioxidants and NRF2 Activators)
- The role of mitochondrial dysfunctions due to oxidative and nitrosative stress in the chronic pain or chronic fatigue syndromes and fibromyalgia patients – 2013
- Oxidative stress and mitochondrial dysfunction in fibromyalgia. – PubMed – 2010
- Roles of Reactive Oxygen and Nitrogen Species in Pain – 2011
- Is Inflammation a Mitochondrial Dysfunction-Dependent Event in Fibromyalgia? – 2012
- Metformin and caloric restriction induce an AMPK-dependent restoration of mitochondrial dysfunction in fibroblasts from Fibromyalgia patients. 2015 – PubMed – NCBI
- Mitochondrion-Permeable Antioxidants to Treat ROS-Burst-Mediated Acute Diseases – 2016
- Melatonin-Mitochondria – 2006
CAM, FMS – Treatment (Tx)
CAM, FMS Tx – Antioxidants & NRF2 Activators
CAM, FMS Tx – Antioxidants: CoQ10
- Benefits of Coenzyme Q10 | Fibromyalgia Natural Relief
- Can coenzyme q10 improve clinical and molecular parameters in fibro… – PubMed – 2013
- Coenzyme Q10 Regulates Serotonin Levels and Depressive Symptoms in Fibromyalgia Patients – 2013
- Effect of coenzyme Q10 evaluated by 1990 and 2010 ACR Diagnostic Criteria for Fibromyalgia and SCL-90-R – 2013
- Fibromyalgia: unknown pathogenesis and a “chicken or the egg” causa… – PubMed – 2012
- NLRP3 inflammasome is activated in fibromyalgia: the effect of coen… – PubMed – 2014
- Oral coenzyme Q10 supplementation improves clinical symptoms and re… – PubMed – 2012
- Oxidative stress and mitochondrial dysfunction in fibromyalgia. – PubMed – 2010
CAM, FMS Tx – Antioxidants & NRF2 Activators: Curcumin
CAM, FMS Tx – Antioxidants: Luteolin
- Brain “fog,” inflammation and obesity – key aspects of neuropsychiatric disorders improved by luteolin – 2015
- Role of Catechol-O-Methyltransferase in the Disposition of Luteolin in Rats – 2011
CAM, FMS Tx – Bacopa
CAM, FMS Tx – Clonidine
- Analgesic synergy between opioid and α2-adrenoceptors – 2014
- Clonidine May Help in Chronic Fatigue Syndrome (CFS) and Fibromyalgia Because – 2013
- Idiopathic Peripheral Neuropathy Responsive to Sympathetic Nerve Blockade and Oral Clonidine – 2012
- Clonidine – clinical pharmacology and therapeutic use in pain management
- Clonidine for management of chronic pain – A brief review of the current evidences – 2014
- THE ROLE OF TOPICAL AGENTS IN PODIATRIC MEDICINE – 2013
- Topical clonidine for neuropathic pain – 2015
CAM, FMS Tx – DHEA
- Influence of cortisol and DHEA-S on pain and other symptoms in post menopausal women with fibromyalgia. – PubMed – NCBI
- Proinflammatory cytokines and DHEA-S in women with fibromyalgia – impact of psychological distress and menopausal status
CAM, FMS Tx – Ginseng
CAM, FMS Tx – Melatonin
Melatonin – Fibromyalgia Pain
- Melatonin therapy in fibromyalgia. – PubMed – NCBI
- Melatonin therapy in fibromyalgia, Commentary – 2006
- Melatonin analgesia is associated with improvement of the descending endogenous pain-modulating system in fibromyalgia – a phase II, randomized, double-dummy, controlled trial – 2014
- The effect of melatonin in patients with fibromyalgia: a pilot study. – PubMed – NCBI
- Adjuvant use of melatonin with fluoxetine (Prozac) for treatment of fibromyalgia. – 2012
- Fibromyalgia–a syndrome associated with decreased nocturnal melatonin secretion. – PubMed – NCBI
- Abnormality of Circadian Rhythm of Serum Melatonin and Other Biochemical Parameters in Fibromyalgia Syndrome – 2011
- A Quest for Better Understanding of Biochemical Changes in Fibromyalgia Syndrome – 2014
- Is the Deficit in Pain Inhibition in Fibromyalgia Influenced by Sleep Impairments? – 2012
Melatonin – Insomnia
- The effectiveness of melatonin for promoting healthy sleep – a rapid evidence assessment of the literature – 2014
- Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. – 2007
- Ramelteon: MedlinePlus Drug Information
CAM, FMS Tx – Naltrexone
- Effects of Naltrexone on Pain Sensitivity and Mood in Fibromyalgia – 2009
- Low-Dose Naltrexone Eases Pain and Fatigue of Fibromyalgia
- Low-Dose Naltrexone Effective Therapy for Fibromyalgia
- Naltrexone for Fibromyalgia – Learn About Research Studies!
CAM, FMS Tx – SAMe
CAM, FMS Tx – Dopamine Support
CAM, FMS Tx – Dopamine Support: Synaptamine
- A Multi-Locus Approach to Treating Fibromyalgia by Boosting Dopaminergic Activity in the Meso-Limbic System of the Brain
- Fibromyalgia patients show an abnormal dopamine response to pain. – PubMed – NCBI
- Reduced presynaptic dopamine activity in fibromyalgia syndrome demo… – PubMed – NCBI
- Stress and dopamine: implications for the pathophysiology of chroni… – PubMed – NCBI
- Hypothesizing that brain reward circuitry genes are genetic antecedents of pain sensitivity and critical diagnostic and pharmacogenomic treatment targets for chronic pain conditions – 2009
CAM, FMS Tx – Vitamin D
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
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