How to Test for Fibromyalgia

Fibromyalgia is a mystery to most doctors, so testing for fibromyalgia can be a big challenge. What is it really? Nerve pain? Muscle pain? Nerve pain felt in the muscles that are confused with muscle pain? Is it thyroid related? Is it injury and structurally related? Or is it my favorite issue of all time that masquerades as fibromyalgia, low dopamine.

I had a patient ten years ago that was a downhill skier and had competed in several Olympic games, which translates into high speed, high impact crashes on fields of ice and snow. She had knee and shoulder pain that was so obviously structural from her sports injuries that we didn’t even discuss it as a potential problem to investigate. Three days. I mean literally three days on her dopamine boosting program based on her organic acids test and she was completely pain free! How could that happen? We were both in disbelief. It was a profound lesson for me as a practitioner that things are not always as they seem.

Chronic pain can be inflammatory in origin. I’ve had dozens of patients whose chronic longstanding back pain vanished with a parasite treatment protocol. How could that be? Well, there are links between the nervous system and GI tract. Irritation in the GI tract triggers signals up the nerves that come from the low back. Therefore, you have a GI inflammatory triggered chronic low back pain. I’ve seen countless, probably several hundred cases of chronic lower back pain resolve with a simple ileocecal valve adjustment. Again, viscero-somatic links where internal organs under duress generate what feels like low back problems.

So, in a world of attempting to diagnose the underpinnings of any type of chronic pain we are up against so many variables even the most careful and considered clinician can be stumped. A doctor in a rush, without thorough training in structural problems, can cause GI issues and even things seemingly remote like food allergies and thyroid problems to be missed.

Dr. David Brady - Diagnosing, Testing and Medicine

Into this mix we find the condition of fibromyalgia. The mechanisms that underlie fibromyalgia are often ignored or entirely misunderstood, it’s often diagnosed in people that don’t have it and an accurate diagnosis is rare.

This problem has been addressed in a recent book by Dr. David Brady called The Fibro Fix, which I highly recommend for anyone, patient or doctor, interested in this area. Dr. Brady is a well respected teacher, researcher and clinician who is a strong leader in our functional medicine community.  I attended a seminar on fibromyalgia that Dr. Brady taught last year in New York and was shocked how poor my own understanding of the condition was at the time. If you have the opportunity to attend a seminar by Dr. Brady I would urge you to go since even a basic understanding of this condition could help a large number of patients in your practice, or at the very least pick up a copy of his book.

Because of the depth of confusion around this subject I want to summarize some of the information Dr. Brady taught us at the conference and give you a general introduction on this issue based on his research and writings. We’ll review the tests for fibromyalgia as well as the many types of fibromyalgia medicine that are frequently used in this article. The main confusion around this condition centers around how doctors diagnose fibromyalgia and the reality that many different and very common medical problems can present in a very similar way to a true fibromyalgia case in regards to symptoms. Mitochondrial dysfunction or adrenal exhaustion and circadian rhythm problems can all trigger fatigue and pain that can be misconstrued as fibromyalgia. In fact, many conditions can trigger chronic pain and body aches that can be blamed on fibromyalgia. The way this condition can get misdiagnosed so easily is just due to hair trigger analysis on the part of doctors. A woman that complains about joint and muscle pain, GI issues like constipation and additional symptoms like insomnia and anxiety will often be diagnosed as having fibromyalgia. While we know in functional medicine that these constellations of symptoms can be related to many other issues from chronic GI infections to thyroid dysregulation.

Ready, Fire, Aim

The rush to judgement of a fibromyalgia diagnosis eliminates any investigative process into what may actually be going on underneath the surface.

The American College of Rheumatology’s official position is that fibromyalgia is a diagnosis of exclusion, meaning because there is such strong overlap between it  and other common health problems, one has to do a complete work up to determine if a fibromyalgia diagnosis is accurate or not. In practical terms we see the diagnosis of fibromyalgia being handed out quickly without thorough analysis of the underlying problems that could be present and this ends up leading to endless frustration and suffering from many patients who stop investigating what might be wrong when they inappropriately get the diagnosis and figure they are stuck with the problem.

One thing I’ve learned in 20 years of practicing functional medicine is that an accurate assessment of the underlying cause of the problem in the beginning of treatment is the absolute key to good patient outcomes. My teacher. Dr. Timmins, used to call the opposite of this “ready, fire, aim” meaning all too often doctors “fire away” with a treatment including potentially dangerous medications, prior to completing a thorough work up. He would always say, “the odds of successful treatment outcomes are entirely predicated on the diagnostic information you gather prior to initiating treatment.” This seems so ridiculously obvious as to not be worthy of stating, however the reality is the majority of patients I treat have been completely let down in this regard and fibromyalgia sufferers are at the top of this list of misdiagnosed or undiagnosed folks. It’s not like there is some tests online or instant analysis that will sort chronic pain out. It requires time, patience and a willingness to be thorough at every step of the way.

The way the diagnostic criteria for fibromyalgia are laid out, it’s very easy to make a snap judgement on a clinicians part and assume that’s the end of the story.  We end up with people with adrenal exhaustion or thyroid problems like Hashimoto’s or hypothyroidism, or even those with energy metabolism problems from poor performing mitochondria all lumped in together with this overly simplistic diagnostic category since patients with these other conditions can present in very similar ways. With doctors under so much pressure to make office visits short, these problems can easily be swept under the diagnostic rug and be missed.

Structural Problems vs. The Central Nervous System

There can also be confusion with various structural issues and many people confuse fibromyalgia type pain with plain old muscle aches, structural problems with joint restrictions and pain coming from various -itises like bursitis or myofascitis.

People with fibromyalgia do feel the pain in the tissues of the body, but the problem is coming from high up in the brain. The brain or nervous system dysfunction is masquerading as a joint, muscle or localized mechanical type of pain. And most chiropractors and massage therapists will realize after a certain number of treatments that those with fibromyalgia, true fibromyalgia patients, will not respond to adjustments, massage work and other types of pain relief such as exercises and stretching, because the problem isn’t located in the periphery of the body, it’s coming from dysfunctional brain signals. If someone does receive significant relief from fibromyalgia symptoms from structural treatments then it wasn’t fibromyalgia in the first place!

True fibromyalgia pain is everywhere throughout the body, not isolated to one area of injury such as the low back or neck. It also is relatively constant, not waxing and waning based on activity levels or repetitive stress use patterns. This type of pain is related to nerves sending the wrong signals back to the brain which are in turn perceived as pain even though there is no trauma or injury occurring, it’s not even an inflammatory type of pain as I used to think. It’s just pain signals being interpreted inappropriately in the brain. It’s almost like a phantom or made up pain, but it’s very, very real to those perceiving it.

Tied to Childhood Trauma

In addition to a strong sense of pain in the soft tissues the condition is accompanied by fatigue, difficultly falling asleep, GI issues and a potential history of trauma in childhood.

The overly active brain can also be tied into an overly active second brain, the nervous system in the GI tract. This combination leads to cognitive symptoms and IBS like symptoms of constipation, bloating or loose stool. So many fibromyalgia patients are also diagnosed with IBS.

Sexual abuse, physical abuse or a highly unstable home environment for a child can lead to the brain being stuck in a “always on” mode that is part of the development of fibromyalgia for many people. Childhood trauma can throw us into a “hypervigilant” state where we are constantly scanning the world for potential dangers, looking for the next bad thing to happen, somewhat anxious about the present moment and trapped in a state of constant negative thoughts.

In terms of lab tests for determining if you have fibromyalgia there are none, in order to diagnose true fibromyalgia one has to eliminate all the other possibilities first and the way we practice medicine now unfortunately doesn’t typically allow for this. Drugs for fibromyalgia include anti-depressants and anti-seizure medications that have been repurposed by drug companies. The research on these drugs doesn’t show impressive results. What we do in functional medicine can help people with a wide variety of pain problems including fibromyalgia. Assessing thyroid and adrenal hormones, chronic low-grade GI infections, neurotransmitter assessments and toxin related issues are generally screened for. Treatments can range from improving the calming neurotransmitters like GABA and serotonin to boosting adrenal and thyroid hormone levels. Many chronic pain/IBS patients have food reactions or GI pathogens which again, when properly treated can be part of the overall equation.

Dr. Larry Bergstrom, Mayo Clinic Miracle Medicine Man

Dr. Larry Bergstrom, director of the Integrative Medicine Department at Mayo Clinic’s Arizona location taught me eight or nine years ago a critical lesson.

I went to visit him at his office in Mayo Clinic’s Phoenix facility. His office had Native American medicine wheels, not exactly what you’d expect at such a prestigious place. Dr. Bergstrom had led the Mayo Clinic’s Internal Medicine Department in Rochester in the past. He was a leader of his profession in an academic medical setting and was no stranger to research, rigorous science or conventional medicine at its highest levels.

In several of our meetings he was the first doctor that pointed out to me that many, not all, but many, of our chronic pain patients, particularly those with true fibromyalgia, have experienced significant emotional and or physical trauma in childhood.  This trauma doesn’t just go away as we get older, especially for women. The trauma stays and what began as emotional trauma can come back as pain, what seems like physical pain. One challenge for all doctors is to be able to bring up these questions about past history and be clear in your ability to find those patients who require emotional support, therapy and counseling work to address childhood abuse. Without sufficient effort to resolve those deeper emotional scars many patients will continually recycle memories, unconsciously reliving their trauma and the physical pain in a sense will keep them trapped in a life full of suffering.

Five years ago a woman in her late 70’s came to my office for a functional medicine evaluation. She was a therapist and had been working as a psychologist for 40 years. She had been sexually abused as a child and we talked at length about her journey, over a lifetime quite literally. We discussed how she could live her life and I wouldn’t say how she could move on from the abuse, but she described it as how could she channel that experience into something of value, have some good come of it. Of course she decided to spend her life helping other abuse victims and although that didn’t change her reality and her childhood experience, it gave her life meaning. We as clinicians need to be comfortable asking these questions of every new patient. “Were you sexually or physically abused in childhood.” Were your parents suffering from alcoholism, mental illnesses or drug addiction.” I am very often the first doctor a patient will tell about their past in this regard and the last thing I would want is a chronic pain patient coming in and out of my clinic without their childhood issues being identified.

I’m not a therapist and I don’t counsel people but I am very good at identifying these folks and getting them into the offices of those that can help. Especially in our role in alternative medicine, we attract a lot of patients with chronic, mystery conditions and I believe more than our fair share of those with physical and emotional abuse issues in their past.

I had a patient just a few weeks ago who I’d been treating for chronic GI pain for almost two years. We’d done every lab and every supplement and every medication known to mankind and still the GI pain came back over and over, a little better, then back. She as in my eyes a functional medicine failure. But why?

Finally she trusted me enough that she explained her grandfather had abused her from age 4 through age 15 and she’d never dealt with it in any way. Her mother kind of knew but didn’t pay attention, as she was also a sexual abuse victim of this man. He had finally died earlier that year and she finally felt free. Free enough to talk about something she’d be hiding and internalizing physically for decades. For someone like this patient, the healing can only truly begin when the underlying trauma is acknowledged and can finally be addressed.