The CDC estimates four million American adults (2% of the adult population) are affected by fibromyalgia. Fibromyalgia can cause varying degrees of challenges, ranging from mild to severe, depending on the individual. Many individuals with fibromyalgia experience limitations in their ability to perform regular activities, work, engage in social interactions, and maintain overall well-being. Conventional approaches to fibromyalgia management often focus on symptom relief, which may not address all contributing factors. This is where a functional medicine approach can be helpful. By addressing the individual's unique factors, functional medicine recognizes the complex nature of fibromyalgia and offers a framework to identify and address potential contributing factors of this challenging condition.
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What is Fibromyalgia?
Fibromyalgia is a chronic and complex rheumatologic disorder affecting millions worldwide. It is characterized by widespread musculoskeletal discomfort, fatigue, and tenderness in specific areas of the body. Fibromyalgia can be understood as a neurosensory disorder that affects the central nervous system's processing of pain signals. The brain's perception and interpretation of pain signals are altered in individuals with fibromyalgia, leading to an amplified pain response even to stimuli that are not typically perceived as painful. This heightened sensitivity is referred to as central sensitization. Along with discomfort, fibromyalgia can involve other neurosensory symptoms, such as heightened sensitivity to touch, temperature, and sound. Fatigue, sleep disturbances, and cognitive difficulties are also common in individuals with fibromyalgia, further highlighting the involvement of the central nervous system. (8, 15)
Fibromyalgia Signs & Symptoms
The cardinal symptom of fibromyalgia is bilateral musculoskeletal discomfort, which involves the upper and lower parts of the body and is present for at least three months. The discomfort is classically described as a dull muscle ache, but patients may also report joint discomfort. Commonly affected areas include the neck, shoulders, chest, hips, knees, and elbows, where specific tender points can be found. (1)
The other hallmark symptom of fibromyalgia is persistent, chronic fatigue, even after getting enough sleep. The fatigue often interferes with daily activities. Minor activities may aggravate the discomfort and fatigue, although prolonged inactivity can also increase symptoms. Sleep disturbances are common; patients may report being light sleepers with frequent wakings in the early morning. (1)
Often called "fibro fog," patients experience cognitive disturbances, such as difficulty paying attention, brain fog, trouble doing tasks requiring rapid thought changes, and poor memory. (1)
Individuals with fibromyalgia may also experience a range of secondary symptoms, such as (1):
- Anxiety and/or depression
- Headaches: migraines and tension headaches
- Irritable bowel syndrome (IBS)
- Gastroesophageal reflux disease (GERD)
- Dry eyes
- Shortness of breath
- Heart palpitations
What Contributes to Fibromyalgia?
While the exact cause of fibromyalgia remains elusive, researchers believe it arises from genetic, environmental, and physiological factors. Several key factors have been identified that may contribute to the development of fibromyalgia.
One primary factor is believed to be abnormal pain processing in the central nervous system. Individuals with fibromyalgia have heightened sensitivity to pain due to changes in how their brain and spinal cord process pain signals. This altered pain processing can amplify pain sensations, leading to widespread and chronic discomfort throughout the body. Researchers have noted imbalances in neurotransmitters, including glutamate, substance P, serotonin, norepinephrine, and dopamine, further supporting this theory. (1)
Genetics may also play a role in fibromyalgia. Although specific genes have not been identified, studies have shown a familial tendency for fibromyalgia, suggesting a genetic component.
Environmental factors such as physical or emotional trauma, infections, or stressful life events can trigger or exacerbate fibromyalgia symptoms. These triggers may cause nervous system changes and lead to fibromyalgia onset in susceptible individuals. (1)
Functional Medicine Labs to Explore for Fibromyalgia
Fibromyalgia can be challenging to diagnose as no specific laboratory tests or imaging studies confirm it. Diagnosis is usually based on the presence of widespread discomfort and the exclusion of other conditions that could account for the symptoms.
Routine Blood Work
A standard lab panel including a CBC, CMP, thyroid hormones, ESR, CRP, and ANA should be included in the initial diagnostic evaluation for patients with fibromyalgia to rule out other conditions that could account for the symptoms. This panel includes lab markers that can screen for infection, anemia, electrolyte imbalances, liver/kidney disease, dysglycemia, thyroid dysfunction, autoimmune disease, and quantify systemic inflammation.
Organic Acids
An organic acids test (OAT) is a comprehensive diagnostic tool that assesses various metabolic markers through the analysis of organic acids present in urine. This test provides valuable insights into several aspects of health, including nutrient deficiencies, oxidative stress, detoxification capacity, neurotransmitter function, and microbial overgrowth. Functional medicine practitioners can identify imbalances and dysfunctions within the body's metabolic processes by analyzing these organic acids. This information may indicate the need for additional testing and can guide personalized wellness plans, including targeted nutritional interventions, lifestyle modifications, and supplementation, to address fibromyalgia's contributing factors.
Infectious Panel
The role of viral and bacterial infections in contributing to fibromyalgia is a subject of ongoing research. While it is clear that fibromyalgia can be triggered or exacerbated by infections, the exact mechanisms linking the two are not yet fully understood. Studies have suggested that viral and bacterial infections, including Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), hepatitis C, HIV, and Lyme disease, may trigger an abnormal immune response that contributes to persistent inflammation. Ordering an infectious panel to screen for immune activation against various infectious agents can screen for chronic infections contributing to fibromyalgia development and symptom severity. (4)
Comprehensive Gut Assessment
Increasing research suggests that the gut microbiome, the diverse community of microorganisms residing in the gastrointestinal tract, may play a role in the development and symptoms of rheumatic conditions. The gut microbiome profoundly influences immune function, neurotransmitter production, and the gut-brain axis, all of which can impact fibromyalgia. Furthermore, studies have shown fibromyalgia patients to have increased rates of dysbiosis, small intestinal permeability, and small intestinal bacterial overgrowth (SIBO) compared to healthy controls (15).
Therefore, a comprehensive gut assessment utilizing a combination of specialty tests, including a comprehensive stool analysis, SIBO breath test, and intestinal permeability screen, can screen for these distinct patterns and shifts in gut health and function related to fibromyalgia.
Nutritional Assessment
Multiple nutrient deficiencies have been associated with fibromyalgia, including vitamins B12 and D, magnesium, calcium, and omega-3 fatty acids (8). A micronutrient test measures the levels of these, among many other essential nutrients.
DUTCH Test
Fibromyalgia is more common in women, partially attributed to the hormonal effects of the menstrual cycle on central nervous system functioning (1). Additionally, patients with fibromyalgia have been found to have abnormal hypothalamic-pituitary-adrenal (HPA) stress responses. A DUTCH test measures both reproductive and adrenal hormones to assess for imbalances in the endocrine pathways related to ovarian and adrenal function.
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Conventional Management for Fibromyalgia
Management of fibromyalgia involves a multimodal approach that includes medication, physical therapy, exercise, stress reduction techniques, and lifestyle modifications. The primary focus is managing discomfort, improving sleep, addressing psychological well-being, and promoting overall physical function. Nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics may be prescribed to help manage discomfort, although their effectiveness in fibromyalgia is limited. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly prescribed to help modulate pain perception, improve sleep, and manage associated depression or anxiety. Muscle-relaxant or anticonvulsant medications may also be considered for symptom management. Additionally, non-pharmacological interventions, including physical therapy, exercise programs, cognitive-behavioral therapy (CBT), and stress reduction techniques, are often recommended to improve physical function, reduce discomfort, and address the emotional impact of fibromyalgia. Management plans are typically tailored to the individual's specific symptoms and may involve a combination of these approaches to achieve optimal symptom control and enhance overall well-being. (5)
Functional Medicine Approach for Fibromyalgia
A functional medicine approach to managing fibromyalgia focuses on personalized and patient-centered care, aiming to identify and address potential contributing factors of the condition. Practitioners create a tailored wellness plan by assessing an individual's medical history, lifestyle factors, genetics, and environmental exposures. They prioritize addressing potential contributing factors, such as nutritional imbalances, hormonal dysregulation, gut health issues, chronic infections, toxins, and psychological stress. This systems-based approach recognizes the interconnectedness of various body systems and aims to restore balance and optimize overall wellness. Lifestyle modifications, nutritional support, and collaborative patient empowerment are key components, encouraging active participation in the wellness process to improve long-term health and vitality.
In addition to the nutritional considerations and supplements discussed in detail below, providers should help patients establish a solid basis for optimal health by advising on the importance of exercise and physical medicine, stress management, sleep, and counseling for trauma. Other complementary and integrative modalities that can be integrated into a holistic wellness plan include chiropractic, massage therapy, acupuncture, and infrared light therapy.
Therapeutic Diet and Nutrition Considerations for Fibromyalgia
A 2019 systematic review revealed that specific diets have shown promise in supporting comfort and enhancing the quality of life for individuals with fibromyalgia. Among the diets investigated, the hypocaloric (low-calorie) diet, the low-FODMAP diet, and the raw vegetarian diet demonstrated positive outcomes. These diets were associated with reduced inflammation markers, improved sleep quality, and decreased levels of anxiety and depression, as observed in the review.
Likely, these diets demonstrate positive health outcomes given their anti-inflammatory natures. By reducing ultra-processed foods and incorporating whole foods rich in antioxidants, omega-3 fatty acids, and phytonutrients, any nutrient-dense, anti-inflammatory diet can help minimize inflammation, support optimal nutrition, improve gut microbiome balance, stabilize weight and energy levels, and positively impact mood, cognitive function, sleep quality, and stress resilience. These factors contribute to a potential reduction in fibromyalgia symptoms and improved quality of life.
Supplements Considerations for Fibromyalgia
Supplements can be used with or as natural alternatives to pharmaceutical medications to support balance identified on testing and improve symptoms related to fibromyalgia. Below is a sample protocol that doctors can use in clinical practice.
Multivitamin
A high-potency multivitamin can provide general nutritional support to help maintain nutritional balance associated with fibromyalgia. A multivitamin can support energy production, immune function, and neurotransmitter synthesis.
Dose: Per label instructions
Duration: Ongoing
5-HTP
5-Hyroxytryptophan (5-HTP) is an amino acid precursor for the neurotransmitter serotonin. Low serotonin levels are associated with fibromyalgia discomfort, mood changes, and sleep disturbances. A 90-day clinical trial demonstrated that 5-HTP improved discomfort intensity, the number of tender points, sleep, fatigue, anxiety, and overall quality of life in patients with fibromyalgia.
Dose: 50-100 mg daily
Duration: 3 months
Magnesium Malate
Magnesium is often supplemented alongside a multivitamin to support ATP production in skeletal muscle and help maintain muscle tone and comfort. Studies show that patients with fibromyalgia tend to have lower blood levels of magnesium compared to healthy controls, and supplementation supports fatigue, sleep, mood, muscle comfort, and tender points.
Dose: 300 mg 2-3 times daily
Duration: 3 months
Fish Oil
Fish oil is rich in omega-3 fatty acids, which are anti-inflammatory and important for brain function. Numerous studies have shown omega-3 fatty acids' ability to support biochemical markers of inflammation, support joint comfort, support mood, and enhance cognitive function.
Dose: 1,000-2,000 mg of combined EPA + DHA daily
Duration: at least 3-6 months
When to Retest Labs
The decision to retest should be determined by clinical necessity, the patient's response to wellness strategies, and patient/doctor preference. Functional medicine labs are typically reordered between 3-12 months after baseline to assess patient progress; however, in some cases, clinical necessity will dictate labs be reordered sooner than this to monitor the patient's health.
Learning More About Fibromyalgia
- Magazine Article: A Comprehensive Review of Complementary and Integrative Treatments of Fibromyalgia: Testing, Supplements, and Therapies
- Integrative Approaches to Pain Management in Rheumatology Patients: Testing, Supplements, and Therapies
- Podcast: Releasing Emotions as it Relates to Pain, Autoimmune, and More with Dr. Christian Gonzalez
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Summary
Fibromyalgia is a complex condition that significantly impacts the affected individual's quality of life and ability to function. A functional medicine approach offers alternative tools and resources to explore and address potential contributing factors. A multimodal, holistic wellness plan may help improve symptom and function scores and allow individuals to regain the freedom to enjoy life.
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