Imagine waking up every morning feeling worn out, achy, and depressed. The fatigue never seems to go away, and anxiety is a constant companion because you just don’t understand what is wrong with you. You’re scared and confused. If it’s this bad now, what will tomorrow bring? This is the experience many people describe who now know that the mysterious symptoms they were suffering from have a name: Fibromyalgia (FM). Once you can put a name to it and begin to understand it, there is hope of managing it and getting your life back.
What is Fibromyalgia?
Fibromyalgia literally means “pain of the tissues and muscles.” It is also known as fibrositis and fibromyositis. It is characterized by inflammation, fatigue and pain primarily in the connective tissues of the body, such as the muscles, tendons, and ligaments. The pain is usually consistent, but it moves around the body. It is a relatively newly discovered disease, in fact a formal diagnosis for fibromyalgia didn’t exist until 1990, and estimates vary as to how prevalent it is. Some say that 3 to 6 million Americans have fibromyalgia while others put it as high as 10 million and it afflicts about 5 million people a year in the United States. It is mostly found in adults, and is much more common in women than in men, especially women of child bearing age. Women suffer from FM more than men at a ratio of 7:1. Unfortunately, fibromyalgia is a diagnosis that many doctors miss altogether or patients are dismissed as hypochondriacs.
Fibromyalgia is considered to be in the family of rheumatoid diseases, a relative of arthritis. In 1990, the first standards of diagnosis were established for fibromyalgia by the American College of Rheumatology. To be definitively diagnosed, a subject must have widespread pain and tenderness in at least 11 of 18 identified tender points or trigger points, usually found in pairs. These points include the base of the neck, the spine, hips, pelvis, elbows, knees, and shoulders. For the diagnosis to hold true, the pain must be experienced for at least 90 consecutive days.
What Are the Symptoms of Fibromyalgia?
Fibromyalgia has been described as an “energy crisis in the body.” It has a number of common symptoms:
- Widespread pain that moves around
- The “Wind Up”: snowballing pain that comes from repetitive, minor physical contact
- Significant fatigue
- Difficulty getting enough quality sleep
- Depression and anxiety
- Numbness or tingling in the extremities
- Poor memory
- Over-sensitivity to heat or cold
- Tension headaches
- Abdominal pain
- Painful menstrual cycles
- Difficulty swallowing
- Irritable bowel syndrome
- Symptoms tend to worsen with increased physical or mental stress, lack of sleep, hormonal changes, and even changes in the weather
What Causes Fibromyalgia?
The exact cause is not known. There seems to be a connection between family history of the illness and risk, thus heredity is considered a possible factor. People who have another rheumatic disease such as arthritis are at increased risk as well. Low serotonin levels and low magnesium levels in the body are also a clue. Fibromyalgia patients often indicate both of these deficiencies.
One trend that interests researchers is that many patients seem to experience the onset of the disease after a physical or emotional trauma in their lives, such as an injury, or a traumatic event like an automobile accident or a physical assault. These kinds of stress are thought to trigger the onset of fibromyalgia in some cases. Other contributing factors may be some kinds of infections (such as a bad bout with the flu) or changes in brain chemistry.
Some evidence suggests a role of hormone imbalance since fibromyalgia predominantly affects middle aged women; a population whose hormones have begun to decline or fall out of youthful balance (Lawrence 2008; Terhorst 2011). Fluctuating hormone levels caused by endocrine dysfunction commonly produce symptoms that are similar to those of fibromyalgia (muscle pain/tenderness, exhaustion, and reduced exercise capacity) (Geenen 2002). I highly suggest saliva testing sex hormones and the adrenal hormone cortisol to check for hormone imbalances. Also, according to Dr. John Lowe, thyroid hormone is the missing ingredient in the treatment of fibromyalgia that is almost universally overlooked. Conventional testing for thyroid issues can prove useless to many that actually need thyroid hormone. For tests and lab work to ask your doctor for see Hypothyroidism Symptoms and Solutions.
The relationship between obesity and chronic pain has been common knowledge for many years but more recent research suggests that this association is particularly true for those with fibromyalgia. In 2010, a study of 215 fibromyalgia patients suggested that nearly 80% of participants were either overweight or obese. These same patients exhibited greater tender point sensitivity, reduced physical strength, reduced lower-body flexibility, shorter sleep duration, and greater restlessness during sleep (Okifuji 2010). A 2011 review article concluded that fibromyalgia patients are 40% more likely to be obese and 30% more likely to be overweight (Ursini 2011).
The frequency of depression and anxiety in fibromyalgia patients has caused some health professionals and loved ones to suspect that the illness was primarily psychological and not a “real” condition. This has generally been dismissed in the last decade or so as more information has been gleaned about fibromyalgia. However, the ambiguity of this illness still haunts some of its own victims and causes them to doubt if it is not all “in my head.” Some patients report that their anxiety is exacerbated by their own guilt about not being able to do what they used to do. But as more hard evidence on fibromyalgia comes out, the legitimacy of the disease becomes more and more confirmed both in the eyes of its sufferers and of the general public.
One more consideration. Lyme disease is the number one vector borne spreading epidemic worldwide, and mimics common diseases such as Fibromyalgia (FM), Chronic Fatigue Syndrome (myalgic encephalomyelitis), autoimmune diseases like rheumatoid arthritis and MS, as well as psychiatric conditions such as depression and anxiety. In 2013 the CDC released new statistics showing that ten times more individuals have been affected with Lyme than previously suspected. Since the blood tests for diagnosing Lyme disease have been shown to be unreliable, we would expect that a certain percentage of those diagnosed with FM are in fact suffering from Lyme disease. Talk with your healthcare provider about the possibility of Lyme disease.
There is no known 100% cure for fibromyalgia. The goal of conventional therapy is to manage and lessen symptoms. The FDA has only approved three specific drugs for fibromyalgia. In June 2007, pregabalin (Lyrica®), an anticonvulsant drug, became the first to be approved. A year later duloxetine (Cymbalta®), an antidepressant, became the second. The most recent addition to this list is the antidepressant milnacipran (Savella®), which was FDA approved in January 2009. Unfortunately, none of these medications are effective for the entire scope of symptoms and disabilities associated with fibromyalgia (Argoff 2002). Many patients either fail to respond or develop significant side effects to these drugs, especially since they are required to be on them long-term (Braz 2011).
The best course of action for most with fibromyalgia seems to be a combination of detoxification, healthy diet, exercise, dietary supplements/herbs and quality sleep.
Exercise. Many have found swimming or water exercises to be especially helpful. Stretching is key, as well as proper warm up and cool down periods. Everyone is different, so try several different types of exercise and use what works best for you. Just remember to pace yourself and be consistent. Exercise should not be painful. If you are experiencing pain, try changing the type, intensity, or duration of your activity.
Adequate restful sleep is very important in the fight against fibromyalgia. Sleeplessness is a typical characteristic of the disease. Research seems to indicate that many patients suffer worse symptoms when they don’t get enough sleep. A pattern of poor sleep over time may even make the risk of developing fibromyalgia greater. Avoid stimulants such as caffeine, especially in the evening or before bed. Consistent exercise is known to help stabilize sleep patterns as well. Some find it beneficial to go to bed and get up at approximately the same time every day. Also, try to make your bedroom as sleep-friendly as possible. Dark, quiet, cool and comfortable are the buzz words here. Bedrooms should be bedrooms, not offices, conference rooms, or entertainment centers.
Gut Health, Cleansing & Detoxifation Help for Fibromyalgia
There is very little available in the way of mainstream medical treatments available for fibromyalgia that are successful. This is a possibly a good thing, since it has motivated both patients and health providers to look for natural alternatives. A recent study from Mayo Clinic stated that approximately 98% of fibromyalgia patients polled used some form of alternative or complimentary therapy to ease their symptoms.
Detoxification, Cleansing, Digestion
The importance of gut health — detoxification, removal of toxins and working on the digestive tract — in my opinion, is imperative. This is something that is often overlooked even by natural health practitioners, but something that can prove very successful in fibromyalgia treatment.
Gut health determines what nutrients are absorbed and what toxins, allergens, and microbes are kept out. It is also directly linked to the health of the entire body. In fact, good intestinal health can be defined as the optimal digestion, absorption, utilization and assimilation of food.
Your gut’s nervous system has been termed as the “second brain”. The gut contains more neurotransmitters than your brain and actually contains a brain of its own. Called the “enteric nervous system”, it is a very complex piece of your body’s biology that is wired to your brain in intricate ways. Your gut-brain and your head-brain continually send messages to each other, and if this message system is interfered with, your health may become impaired.
Most with fibromyalgia report digestive difficulties. Irritable bowel syndrome, diarrhea, bloating and gas are often reported. Using an oxygen-based cleanser along with an herbal liver cleanse can be very effective. I recommend doing several digestive tract and liver cleanses back-to-back and then at least three times yearly. Repopulating your gut with a spore-bearing probiotic such as Latero-Flora or Floratrex probiotic is very helpful in improving immune system function. Taking a digestive enzyme with every meal usually helps with bloating and gas. See The Importance of Full Body Cleansing.
Candida & Parasite Cleansing. Testing for Candida over-growth and parasites will most likely show as positive in most people and especially those with fibromyalgia. This can be addressed with an effective Candida and parasite cleanse that includes a combination of anti-fungal and antibacterial botanicals.
Food Allergies. Food allergies can undermine anyone’s health and well-being. Eliminating foods that you are sensitive to is an appropriate beginning step. Some of the more popular offending foods are gluten, dairy, corn, peanuts, red meat, hydrogenated oils and foods high in yeast. A healthy diet of organic vegetables, berries, green drinks, cold-water fish, pasture-raised poultry, organic rice and healthy oils such as olive oil and coconut oil can be very helpful.
Lymphatic Drainage. When the lymph system gets sluggish (due to illness, surgery, toxic overload or lack of activity), lymph fluid begins to back up. The results can be swelling, joint pain, nausea and fatigue. Stagnant lymph may be stored in lymph nodes for a long period of time but eventually becomes too toxic for the body to handle well. A sluggish lymphatic system not only affects the building, repair and waste disposal systems, but the body’s defenses against foreign substances are also impaired. Effective ways to keep the lymph moving are rebounding, dry skin brushing and deep breathing exercises.
Adrenals & Stress Reduction. The adrenals also play an important role in the immune system, and are responsible for the balance of hormones throughout the body. Strong, efficient adrenal glands are vital to both genders and during all cycles of life: for young people, through the child-bearing years, into menopause, and beyond. Many suffering from fibromyalgia usually experience high stress levels in trying to deal with a health concern that seemingly has not definitive answers. High stress levels can result in adrenal malfunction which results in hormone imbalance. See Stressed and Fatigued? Check Your Adrenals.
More Natural Health Suggestions for Fibromyalgia
- Boosting Serotonin Levels seems to be beneficial to most patients. 5-Hydroxytryptophan (5-HTP) is a supplement that when ingested converts into serotonin in the body. One study indicated that most patients experienced significant improvement in pain, sleeplessness, anxiety, and fatigue after taking 100 mg. three times per day for 30 days. Results were even better after 90 days.
- Magnesium is another big player in supplemental remedies. Since magnesium is so important to the fibromyalgia patient, I would like to park here and talk a bit more about this mineral and how to get more of it in your diet. Magnesium is involved in over 300 enzymatic reactions in the body. It is particularly critical to proper production and metabolism of energy (ATP) and muscle functions. Most fibromyalgia patients are deficient in magnesium. This creates fatigue and a lack of energy, as well as muscle pain. In review, magnesium makes such a difference in the lives of fibro patients because it is so critical in metabolism of energy and in proper muscle function. It can be found in high concentrations in many foods, including beans, nuts, grains, fish, grass-fed meat, and dark green vegetables such as avocados, broccoli, and spinach. Deficiency can also lead to irregular heartbeat, nerve disorders, and circulation problems. Magnesium also works with calcium, and enables it to be absorbed properly into the body.
- Vitamin B6 should also be taken along with any magnesium supplements, as B6 works to allow greater absorption of magnesium into the cells. I use and recommend magnesium orotate taken orally and magnesium oil applied transdermally. Patients with fibromyalgia should consider having a red blood cell magnesium test to ensure that they are not deficient in this important nutrient.
- Vitamin D – Since those with fibromyalgia syndrome have impaired mobility, they usually get less exposure to sunlight. This contributes to the vitamin D deficiency frequently observed in this population (Bhatty 2010, Olama 2013). In one trial involving 100 women with fibromyalgia, 61% were found to be vitamin D deficient (blood levels of 25-hydroxyvitamin D.
- B-vitamins – B-vitamins were reported in a survey to be used by a quarter of fibromyalgia patients (Wahner-Roedler 2005). Homocysteine levels are kept in check by adequate B-vitamin intake. In one study, women with fibromyalgia were shown to have higher levels of homocysteine in their cerebrospinal fluid than healthy controls (Regland 1997). Other evidence indicates that a Myers’ Cocktail, which consists of an intravenous infusion of several vitamins (i.e., B-complex vitamins), may be useful in fibromyalgia (Gaby 2002; Ali 2009). Also, B-vitamins are essential for maintaining optimal mitochondrial function (Depeint 2006).
- Malic Acid is a substance found in many fruits, with especially high levels in apples. It is involved in the production of energy in the body. When malic acid levels are low, the body turns to less efficient ways of making energy, and this causes lactic acid to accumulate. Lactic acid causes muscle pain and fatigue. Supplementation with a combination of magnesium orotate and malic acid is especially effective.
- Increasing Nitric Oxide Levels. Researchers from Washington State University were successful in decreasing fibromyalgia pain by increasing the production of nitric oxide (NO) from endothelial cells. NO delivers nutrients to muscles by dilating blood vessels. Patients with fibromyalgia have low levels of nitric oxide. This deprives their muscles of oxygen-rich blood and nutrients. Eventually, harmful toxins build-up and cause debilitating pain. Supplements found to increase nitric oxide are pomegranate extract, cocoa polyphenols and Super-Oxide Dismutase (SOD).
- Coenzyme Q10 and Ginkgo Biloba combined shows great promise. One study found that 64% of subjects experienced significant relief from symptoms after taking these supplements together.
- Acylcarnitine is a substance that is important to energy production as well. Many fibromyalgia patients are deficient in this. Supplementation of 500-1000 mg. daily for 12 weeks has proven useful.
- Oregano Oil can help to address SIBO which is small intestinal bacteria overgrowth. SIBO leads to systemic overproduction and absorption of toxins that impair brain/nerve and muscle mitochondrial functions. Bacterial overgrowth produces Dlactic acid which is a neurotoxin as well as a metabolic poison in abnormal amounts. It can cause fatigue, muscle pain and problems with cognition. Bacterial overgrowth can produce hydrogen sulfide. Hydrogen sulfide is also a neurotoxin / metabolic poison and can also cause fatigue, muscle pain and dyscognition. Bacterial overgrowth can produce tryptophanase. Tryptophanase digests tryptophan which is the main building block for serotonin and ultimately melatonin. The literature shows that “fibromyalgia patients have been shown to be low in tryptophan which means poor sleep and increases in pain, fatigue, carbohydrate cravings, and depression. Tryptophan depletion leads to melatonin deficiency which in turn leads to sleep disturbances, mitochondrial impairment and oxidative stress as well as muscle fatigue.” Migraine Headaches, Hypothyroidism and Fibromyalgia: Assessments and Therapeutic Approaches using Integrative Chiropractic, Naturopathic, Osteopathic and Functional Medicine by Dr. Alex Vasquez.
- Essential Fatty Acids (EFA) are helpful too. Clean fish oil, flaxseed oil, and primrose oil are good sources for EFA’s. These fatty acids aid in producing series 1 and 3 prostaglandins which help reduce inflammation. Stay away from animal fats in the diet, as these spawn series 2 prostaglandins, which increase inflammation.
- Ginger acts as an anti-inflammatory agent and helps with muscle and joint pain. Researchers have also discovered that ginger may stymie the growth of “Substance P,” which is a pain mediator found at elevated levels in many patients.
- St. John’s Wort helps many patients with both depression and sleeplessness. It also works well in conjunction with 5-HTP and magnesium.
- Massage Therapy is a therapy that is helpful in many cases. Some love it, but others complain that it is painful for them at times. Everyone is different, and as is the nature of fibromyalgia, one’s levels and locations of pain vary. A massage therapist must be sensitive to this when working on a subject. Short sessions are usually best. Some have even taught family members what works best for them. A form called “deep muscle massage” is preferred by many. It’s wonderful to have a masseuse right on the premises! (That would be nice for all of us, fibro or not). Heat therapy, cold therapy, sauna therapy and hydrotherapy (warm baths) are often used either standing alone or in combination with massage.
- Chiropractic. Chiropractors aim to correct misalignments of the spine and pelvis through the use of hands-on adjustments. As joint motion improves, fibromyalgia patients often discover that the excruciating pain can be reduced or, in some cases, eliminated. Once this pain is under control, other symptoms associated with fibromyalgia such as fatigue, sleep deprivation, and depression may diminish. Chiropractic care has helped thousands of patients return to their normal lives. Retired Brig. Gen. Becky Halstead, the first woman General in the U.S. Army to command in Iraq, suffered from fibromyalgia during her service. She states: “The adjustments and nutritional advice I received from my chiropractor helped in treating the fibromyalgia and made me feel better on a day-to-day basis.”
- Aromatherapy is also found useful by some patients. A soak in a hot tub with essential oils of lavender, frankincense, juniper, or chamomile can be soothing to both the body and the spirit.
Before embarking on any of the above recommendations, I highly recommend consulting with a knowledgeable Naturopath, Functional Medicine Doctor or Chiropractor in which you can discuss your symptoms and this article as well as getting help and guidance in monitoring your path to wellness. Often the success or failure of any protocol can be partially linked to knowledgeable guidance, high amounts of encouragement and frequent accountability.
References & Research
Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med. 2000;160(2):221-227.
Abdul HM, Calabrese V, Calvani M, Butterfield DA. Acetyl-L-carnitine-induced up-regulation of heat shock proteins protects cortical neurons against amyloid-beta peptide 1-42-mediated oxidative stress and neurotoxicity: implications for Alzheimer’s disease. J Neurosci Res. 2006;84(2):398-408.
Abdullah M, et al. Mitochondrial myopathy presenting as fibromyalgia: a case report. J Med Case Reports. 2012 Feb 10;6(1):55.
Akkus S, et al. Levels of lipid peroxidation, nitric oxide, and antioxidant vitamins in plasma of patients with fibromyalgia. Cell Biochem Funct. 2009 Jun;27(4):181-5.
Albert JE, et al. S-adenosyl-L-methionine (SAMe) as an adjunct for resistant major depressive disorder: an open trial following partial or nonresponse to selective serotonin reuptake inhibitors or venlafaxine. J Clin Psychopharmacol. 2004 Dec;24(6):661-4.
Ali A, Njike VY, Northrup V, et al. Intravenous micronutrient therapy (Myers’ Cocktail) for fibromyalgia: a placebo-controlled pilot study. J Altern Complement Med. 2009 Mar;15(3):247-57.
Alok R, Das SK, Agarwal GG, et al. Relationship of severity of depression, anxiety and stress with severity of fibromyalgia. Clin Exp Rheumatol. 2011 Nov-Dec;29(6 Suppl 69):S70-2. Epub 2012 Jan 3.
Altindag O, Celik H. Total antioxidant capacity and the severity of the pain in patients with fibromyalgia. Redox Rep. 2006;11(3):131-135.
Argoff CE. Pharmacologic management of chronic pain. J Am Osteopathic Assoc. 2002;102(9suppl3):521–526.
Arnold LM, Clauw DJ, McCarberg BH. Improving the recognition and diagnosis of fibromyalgia. Mayo Clin Proc. 2011;86(5):457-464.
Arnold LM, Clauw DJ. Fibromyalgia syndrome: practical strategies for improving diagnosis and patient outcomes: Am J Med. 2010 Jun;123(6):S2.
Arnold LM, Crofford L3, Mease PJ, et al. Patient perspectives on the impact of fibromyalgia. Patient Educ Couns. 2008;73(1):114-120.
Arranz LI, Canela MA, Rafecas M. Dietary aspects in fibromyalgia patients: results of a survey on food awareness, allergies, and nutritional supplementation. Rheumatol Int. 2011;22:22.
Arranz LI, Canela MA, Rafecas M. Fibromyalgia and nutrition, what do we know? Rheumatol Int. 2010;30(11):1417-1427.
Bagis S, Karabiber M, As I, et al. Is magnesium citrate treatment effective on pain, clinical parameters and functional status in patients with fibromyalgia? Rheumatol Int. 2012 Jan 22. [Epub ahead of print].
Bagis S, Tamer L, Sahin G, et al. Free radicals and antioxidants in primary fibromyalgia: an oxidative stress disorder? Rheumatol Int. 2005;25(3):188-190.
Basnet P, Skalko-Basnet N. Curcumin: an anti-inflammatory molecule from a curry spice on the path to cancer treatment. Molecules. 2011;16(6):4567-4598.
Becker S, Schweinhardt P. Dysfunctional neurotransmitter systems in fibromyalgia, their role in central stress circuitry and pharmacological actions on these systems. Pain Res Treat. 2012;741746:2.
Bhatty SA, Shaikh NA, Irfan M, et al. Vitamin D deficiency in fibromyalgia. J Pak Med Assoc. 2010;60(11):949-951.
Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. 1998;3(4):271-280.
Birkmayer GD, Kay GG, Vurre E, et al. [Stabilized NADH (ENADA) improves jet lag-induced cognitive performance deficit]. Wien Med Wochenschr. 2002;152(17-18):450-4.
Birkmayer JG, Vrecko C, Volc D, et al. Nicotinamide adenine dinucleotide (NADH)–a new therapeutic approach to Parkinson’s disease. Comparison of oral and parenteral application. Acta Neurol Scand Suppl. 1993;146:32-5.
Braz Ade S, de Paula AP, Diniz Mde F, de Almeida RN. Non-pharmacological therapy and complementary and alternative medicine in fibromyalgia. Rev Bras Reumatol. 2011;51(3):269-282.
Burgmer M, Pogatzki-Zhan E, Gaubitz M, et al. Altered brain activity during pain processing in fibromyalgia. Neuroimage. 2009 Jan 15;44(2):502-8. Epub 2008 Sep 24.
Buskila D, Press J, and Abu-shakra M. Fibromyalgia in systemic lupus erythematosus: prevalence and clinical implications. Clin Rev Allergy Immunol. 2003 Aug;25(1):25-8.
Buskila D, Sarzi-Puttini P. Biology and therapy of fibromyalgia. Genetics aspects of fibromyalgia syndrome. Arthritis Res Ther 2006; 8:218-22.
Calder PC. Omega-3 Fatty acids and inflammatory processes. Nutrients. 2010;2(3):355-374.
Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist SD. A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain. 2010;151(2):530-539.
Caruso I, et al. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990 May-Jun;18(3):201-9.
Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536-541.
Clauw DJ, Arnold LM, McCarberg BH. The science of fibromyalgia. Mayo Clin Proc. 2011;86(9):907-911.
Cordero MD, Alcocer-Gomez E, de Miguel M, et al. Coenzyme Q(10): a novel therapeutic approach for Fibromyalgia? case series with 5 patients. Mitochondrion. 2011;11(4):623-625.
Cordero MD, et al. Mitochondrial dysfunction and mitophagy activation in blood mononuclear cells of fibromyalgia patients: implications in the pathogenesis of the disease. Arthritis Res Ther. 2010b;12(1):R17.
Cordero MD, et al. Mitochondrial dysfunction in skin biopsies and blood mononuclear cells from two cases of fibromyalgia patients. Clin Biochem. 2010a Sep;43(13-14):1174-6.
Crofford LJ, Appleton BE. Complementary and alternative therapies for fibromyalgia. Curr Rheumatol Reports 2001; 3:147-56.
Cuatrecasas G, Gonzalez MJ, Alegre C, et al. High prevalence of growth hormone deficiency in severe fibromyalgia syndromes. J Clin Endocrinol Metab. 2010;95(9):4331-4337.
Cuatrecasas G. Fibromyalgic syndromes: could growth hormone therapy be beneficial? Pediatr Endocrinol Rev. 2009;4:529-533.
Dadabhoy D, Crofford LL, Spaeth M, Russell IJ, Clauw DJ. Biology and therapy of fibromyalgia. Evidence-based biomarkers for fibromyalgia syndrome. Arthritis Res Ther 2008; 10:211.
de Miquel CA, Campayo JG, Florez MT, et al. Interdisciplinary consensus document for the treatment of fibromyalgia. Actas Esp Psiquiatr. 2010;38(2):108-120.
Demarin V, Podobnik SS, Storga-Tomic D, et al. Treatment of Alzheimer’s disease with stabilized oral nicotinamide adenine dinucleotide: a randomized, double-blind study. Drugs Exp Clin Res. 2004;30(1):27-33.
Depeint F, et al. Mitochondrial function and toxicity: role of B vitamins on the one-carbon transfer pathways. Chem Biol Interact. 2006 Oct 27;163(1-2):113-32. Epub 2006 May 24.
Diatchenko L, Nackley AG, Slade GD, et al. Idiopathic pain disorders–pathways of vulnerability. Pain. 2006 Aug;123(3):226-30. Epub 2006 Jun 13.
Flanigan R, et al. D-ribose aids fatigue in aging adults. J Altern Complement Med. 2010 May;16(5):529-30.
Forsyth LM, Preuss HG, MacDowell AL, et al. Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome. Ann Allergy Asthma Immunol. 1999 Feb;82(2):185-91.
Gaby AR. Intravenous nutrient therapy: the “Myers’ cocktail”. Altern Med Rev. 2002 Oct;7(5):389-403.
Gardner A, Boles RG. Beyond the serotonin hypothesis: mitochondria, inflammation and neurodegeneration in major depression and affective spectrum disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Apr 29;35(3):730-43.
Gebhart B, Jorgenson JA. Benefit of ribose in a patient with fibromyalgia. Pharmacotherapy. 2004 Nov;24(11):1646-8.
Geenen R, Jacobs JW, Bijlsma JW. Evaluation and management of endocrine dysfunction in fibromyalgia. Rheum Dis Clin North Am. 2002;28(2):389-404.
Glombiewski JA, Sawyer AT, Gutermann J, Koenig K, Rief W, Hofmann SG. Psychological treatments for fibromyalgia: a meta-analysis. Pain. 2010;151(2):280-295.
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292(19):2388-2395.
Goldenberg DL. Fibromyalgia syndrome a decade later: what have we learned? Arch Intern Med. 1999;159(8):777-785.
Goldenberg, MD. Clinical manifestations and diagnosis of fibromyalgia in adults. In: UpToDate, Peter H Schur, MD, Paul L Romain, MD (Eds), UpToDate, Waltham, MA, 2011.
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. 2002;46(5):1333-1343.
Hassett AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin North Am 2009; 35:393.
Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007;369:946–55.
Holdcraft LC, Assefi N, Buchwald D. Complementary and alternative medicine in fibromyalgia and related syndromes. Best Pract Res Clin Rheumatol 2003;17:667-83.
Hussain SA, Al K, II, Jasim NA, Gorial FI. Adjuvant use of melatonin for treatment of fibromyalgia. J Pineal Res. 2011;50(3):267-271.
Jacobsen S, et al. Oral S-adenosylmethionine in primary fibromyalgia. Double-blind clinical evaluation. Scand J Rheumatol. 1991;20(4):294-302.
Jung HJ, Park EH, Lim CJ. Evaluation of anti-angiogenic, anti-inflammatory and antinociceptive activity of coenzyme Q(10) in experimental animals. J Pharm Pharmacol. 2009;61(10):1391-1395.
Kadetoff D, Lampa J, Westman M, Andersson M, Kosek E. Evidence of central inflammation in fibromyalgia – Increased cerebrospinal fluid interleukin-8 levels. J Neuroimmunol. 2012;242(1-2):33-38.
Karajibani M, et al. Effect of vitamin E and C supplements on antioxidant defense system in cardiovascular disease patients in Zahedan, southeast Iran. J Nutr Sci Vitaminol (Tokyo). 2010;56(6):436-40.
Ko GD, et al. Omega-3 fatty acids for neuropathic pain: case series. Clin J Pain. 2010 Feb;26(2):168-72.
Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26-35.
Le Goff P. Is fibromyalgia a muscle disorder? Bone Spine. 2006 May;73(3):239-42.
Leger D, Bayon V. Societal costs of insomnia. Sleep Med Rev. 2010;14(6):379-389.
Littarru GP, Tiano L. Bioenergetic and antioxidant properties of coenzyme Q10: recent developments. Mol Biotechnol. 2007;37(1):31-37.
Lucas HJ, Brauch CM, Settas L, Theoharides TC. Fibromyalgia–new concepts of pathogenesis and treatment. Int J Immunopathol Pharmacol. 2006;19(1):5-10.
Luciano JV, Martinez N, Penarrubia-Maria MT, et al. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: a randomized controlled trial. Clin J Pain. 2011;27(5):383-391.
Mahdi AA, et al. Abnormality of circadian rhythm of serum melatonin and other biochemical parameters in fibromyalgia syndrome. Indian J Biochem Biophys. 2011 Apr;48(2):82-7.
Marcus DA, Bernstein C, Rudy TE. Fibromyalgia and headache: an epidemiological study supporting migraine as part of the fibromyalgia syndrome. Clin Rheumatol. 2005;24(6):595-601.
Matthana MH. The relation between vitamin D deficiency and fibromyalgia syndrome in women. Saudi Med J. 2011 Sep;32(9):925-9.
Mease PJ, Arnold LM, Crofford LJ, et al. Identifying the clinical domains of fibromyalgia: contributions from clinician and patient Delphi exercises. Arthritis Rheum. 2008;59(7):952-960.
Merchant RE, et al. Nutritional supplementation with Chlorella pyrenoidosa for patients with fibromyalgia syndrome: a pilot study. Phytother Res. 2000 May;14(3):167-73.
Moldofsky H. Rheumatic manifestations of sleep disorders. Curr Opin Rheumatol. 2010;22(1):59-63.
Nordqvist C. What Is Fibromyalgia? What Causes Fibromyalgia? Available at: http://www.medicalnewstoday.com/articles/147083.php Accessed 3/21/2012.
Okifuji A, Bradshaw DH, Olson C. Evaluating obesity in fibromyalgia: neuroendocrine biomarkers, symptoms, and functions. Clin Rheumatol. 2009;28(4):475-478.
Okifuji A, Donaldson GW, Barck L, Fine PG. Relationship between fibromyalgia and obesity in pain, function, mood, and sleep. J Pain. 2010;11(12):1329-1337.
Olama SM, Senna MK, Elarman MM, et al. Serum vitamin D level and bone mineral density in premenopausal Egyptian women with fibromyalgia. Rheumatol Int. 2013 Jan;33(1):185-92.
Ozgocmen S, Catal SA, Ardicoglu O, Kamanli A. Effect of omega-3 fatty acids in the management of fibromyalgia syndrome: Int J Clin Pharmacol Ther. 2000 Jul;38(7):362-3.
Pfeiffer A, Thompson JM, Nelson A, et al. Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study. Am J Phys Med Rehabil. 2003;82(3):186-191.
Pieczenik SR, Neustadt J. Mitochondrial dysfunction and molecular pathways of disease. Exp Mol Pathol. 2007 Aug;83(1):84-92.
Prados G, Miro E. Fibromyalgia and sleep: a review. Rev Neurol. 2012;54(4):227-240.
Regland B, et al. Increased concentrations of homocysteine in the cerebrospinal fluid in patients with fibromyalgia and chronic fatigue syndrome. Scand J Rheumatol. 1997;26(4):301-7.
Reiter RJ, Acuna-Castroviejio D, Tan DX. Melatonin therapy in fibromyalgia. Curr Pain Headache Rep 2007; 11:339–342.
Rico-Villademoros F, Calandre EP, Rodriguez-Lopez CM, et al. Sexual functioning in women and men with fibromyalgia. J Sex Med. 2012 Feb;9(2):542-9.
Rossini M, Di Munno O, Valentini G, et al. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. 2007;25(2):182-188.
Saber AA, Boros MJ, Mancl T, Elgamal MH, Song S, Wisadrattanapong T. The effect of laparoscopic Roux-en-Y gastric bypass on fibromyalgia. Obes Surg. 2008;18(6):652-655.
Sadreddini S, Molaeefard M, Noshad H, et al. Efficacy of Raloxifen in treatment of fibromyalgia in menopausal women. Eur J Intern Med. 2008 Jul;19(5):350-5.
Sarac AJ, Gur A. Complementary and alternative medical therapies in fibromyalgia. Curr Pharm Des. 2006;12(1):47-57.
Sarzi Puttini P, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-L-tryptophan: a 90-day open study. J Int Med Res. 1992 Apr;20(2):182-9.
Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial. Pain. 2011;152(2):361-369.
Schwarz MJ, et al. Evidence for an altered tryptophan metabolism in fibromyalgia. Neurobiol Dis. 2002 Dec;11(3):434-42.
Sendur OF, Tastaban E, Turan Y, Ulman C. The relationship between serum trace element levels and clinical parameters in patients with fibromyalgia. Rheumatol Int. 2008;28(11):1117-1121.
Sendur OF, Turan Y, Tastaban E, et al. Serum antioxidants and nitric oxide levels in fibromyalgia: a controlled study. Rheumatol Int. 2009;29(6):629-633.
Sengupta K, Kolla JN, Krishnaraju AV, et al. Cellular and molecular mechanisms of anti-inflammatory effect of Aflapin: a novel Boswellia serrata extract. Mol Cell Biochem. 2011;354(1-2):189-197.
Skarpanska-Stejnborn A, et al. Effects of oral supplementation with plant superoxide dismutase extract on selected redox parameters and an inflammatory marker in a 2,000-m rowing-ergometer test. Int J Sport Nutr Exerc Metab. 2011 Apr;21(2):124-34.
Spaeth M, Rizzi M, Sarzi-Puttini P. Fibromyalgia and sleep. Best Pract Res Clin Rheumatol. 2011;25(2):227-239.
Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Altern Complement Med. 2006;12(9):857-862.
Terhorst L, Schneider MJ, Kim KH, et al. Complementary and alternative medicine in the treatment of pain in fibromyalgia: a systematic review of randomized controlled trials. J Manipulative Physiol Ther. 2011 Sep;34(7):483-96. Epub 2011 Jun 24.
Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clin Rheumatol. 2012;31(1):55-66.
Thompson ME and Barkhuizen A. Fibromyalgia, hepatitis C infection, and the cytokine connection. Curr Pain Headache Rep. 2003 Oct;7(5):342-7.
Tits M. [Fibromyalgia and physical therapy]. Rev Med Brux. 2011 Sep;32(4):393-7.
Traynor LM, Thiessen CN, Traynor AP. Pharmacotherapy of fibromyalgia. American Journal of Health-System Pharmacy. July 15, 2011 2011;68(14):1307-1319.
U.S. Department of Agriculture. USDA database for the Oxygen Radical Absorbance Capacity (ORAC) of Selected Foods. 2007. Available at: http://www.ars.usda.gov/SP2UserFiles/Place/12354500/Articles/AICR07_ORAC.pdf
Ursini F, Naty S, Grembiale RD. Fibromyalgia and obesity: the hidden link. Rheumatol Int. 2011;31(11):1403-1408.
Wahner-Roedler DL, Elkin PL, Vincent A, et al. Use of complementary and alternative medical therapies by patients referred to a fibromyalgia treatment program at a tertiary care center. Mayo Clin Proc. 2005;80(1):55-60.
Wang C, Schmid CH, Rones R, et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363(8):743-754.
Wolfe F, Cathey MA, and Kleinheksel SM. Fibrositis (Fibromyalgia) in rheumatoid arthritis. J Rheumatol. 1984 Dec;11(6):814-8.
Wolfe F, Clauw D, Fitzcharles MA, Goldenberg D, Katz RS, Mease P. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62: 600–10
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007 Jun;36(6):339-56.