Fibromyalgia can be a particularly difficult condition to address conventionally, but Functional Medicine really has a lot to offer here. In this podcast, we mine the wealth of information that Dr. David Brady brings to the table on this important topic, including:
- The signs and symptoms of fibromyalgia and how it is diagnosed (previously-defined tender points are no longer used!) – see also Dr. Brady’s questionnaire at www.fibrofix.com
- What other mimicking conditions need to be considered or ruled out
- How fibromyalgia differs from chronic fatigue syndrome—vastly different disorders that are commonly confused
- Why not all pain is driven by inflammation
- How not to fall into the trap of only looking at mitochondrial dysfunction
- Organic acids, catecholamines, food reactivity and other relevant labs for assessment and tracking
- Childhood and adult stress patterns in (especially female-dominated) fibromyalgia, and how that factors into interventions
- Additional intervention options such as sleep support, energy pathways, detox, exercise, diet, immune balancing to reset metabolic patterns and promote recovery
Dr. DAVID M. BRADY, is a leading naturopathic medical doctor at Whole Body Medicine in Fairfield, Connecticut. He is the VP of Health Sciences and the director of the Human Nutrition Institute at the University of Bridgeport and the chief medical officer of Designs for Health, Inc., and Diagnostic Solutions Laboratory, LLC. Dr. Brady is a highly sought after presenter and prolific author of medical papers and research articles on fibromyalgia as well as a dedicated champion and advocate for patients suffering with a fibromyalgia diagnosis. Learn more at DrDavidBrady.com and FibroFix.com.
Links
- 2011 Modification of the American College of Rheumatology Diagnostic Criteria for Fibromyalgia
- Fibromyalgia Syndrome Clinical Reasoning Guide
- www.fibrofix.com
- Schneider et al., Commentary: Differential Diagnosis of Fibromyalgia 2006
- Brady & Schneider, Pain and Fatigue: When It’s Fibromyalgia And When It’s Not 2012
Podcast sponsored by Designs For Health
Designs for Health is a professional brand, offered exclusively to health care professionals and their patients through referral. By providing comprehensive support through our extensive line of nutritional products, our research and education division, and our practice development services, we are able to maximize the potential for successful clinical health outcomes.
K. Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine. I’ am your host Dr. Kara Fitzgerald. Today, we are talking to a very long friend of mine. I’ve been working with him for years, Dr. David Brady. We’re going to be covering all things fibromyalgia with, again as always, a focus on what we can think about with regard as clinician, so how we can address this more fruitfully in our practice.
Let me tell you a little bit about David. He is a leading naturopathic doctor at Whole Body Medicine in Fairfield, Connecticut. Actually, he’s a leading MD beyond his clinic I’d say. Really, globally, you’ve been doing great work over the years. He’s also vice president of Health Sciences and the director of the Human Nutrition Institute at the University of Bridgeport. He’s chief medical officer at Designs for Health as well as Diagnostic Solutions Laboratory.
Dr. Brady is a sought after presenter and prolific author of medical papers and research articles on fibromyalgia, as well as dedicated champion and advocate for patients suffering with fibromyalgia diagnosis. You are likely aware of the fact that he’s recently published The Fibro Fix, a really great book. You can learn about that at fibrofix.com and you can also read more about David and some of the work he’s doing at drdavidbrady.com.
Incidentally, we will have all of these links posted to the webpage for this podcast. David’s also again, he’s published on fibromyalgia. In fact, arguably from a functional perspective, he’s published the best papers out there. His book opens those up in language to them for the layperson and expands on some concepts. We will have links to a couple of his research papers on our site and you’ll be able to access the full text and I just strongly recommend you do.
There’s a great algorithm in his 2006 paper that I’ve used, not only in my practice but when I’m educating folks because there’s really nothing else out there like it. David, welcome to New Frontiers.
Dr. D. Brady: Thanks, Kara. It’s a pleasure to be on your podacstpodcast … such an old and dear friend and respected colleague so I appreciate the opportunity to talk about something that is a big passion of mind to try to disseminate more accurate information about and clear up some of the myths that seem to have persist about this disorder.
K. Fitzgerald: Not only are you clearing this up and straightening things out but you’re really expanding the toolkit for clinicians of all stripes. Tell me about how you ended up moving into the topic of fibromyalgia to this extent. Yeah, give me the back story.
Dr. D. Brady: That’s an interesting story. Before I trained in clinical nutrition and ultimately, in naturopathic medicine and really, most accurately in functional medicine long, long ago, over 25 years ago. Now I went to chiropractic school and that was my first foray into sort of my health care education with the electronics engineer before that. I got out of chiropractic school and I went there thinking I was going to do a lot of biomechanical research and marry up my engineering degree to this great training in biomechanics and physical medicine and all and it really took a left turn.
A lot of my mentors at Texas Chiropractic College where I went to school were really quite progressive interventional nutritionists and botanical medicine practitioners, sort of what we would move more akin to the modern naturopathic medical doctor. I was really inspired by that then I found functional medicine. So I really started going down more of a path of solving complex metabolic chronic disease situations and I got out of chiropractic school and went into practice and I started seeing these patients that had fibromyalgia or at least thought they did, said they did.
Some of them, I was able to get better with all of the stuff I’ve learned in functional medicine going at it from a metabolic standpoint and so forth and then there was a subset of them clearly that were a different animal and they did have this sort of chronic pain perception issue that’s centrally mediated, very complicated disorder that was really difficult to get better and I realized very quickly that I was not equipped to deal with them.
I certainly wasn’t trained on fibromyalgia enough in my chiropractic education. What I was told back then and all other health care providers and even to this day unfortunately, what they learn about it in training is not much. Sometimes it’s talked about in a dismissive type of term like there’s doubt of whether it’s good or real simple entity and then what you’re told is not that helpful and I come to find out is usually wrong and inaccurate. So I figured out I had to make myself an expert on this topic if I had any hope to help these patients get better which I was really dedicated to doing. I found a kindred spirit in a colleague, Michael Schneider who’s now an NIH-funded researcher in integrative medicine in physical medicine at the University of Pittsburgh.
We were both teaching myofascial pain seminars together, different hands-on physical medicine approaches to myofascial pain. We realized that fibromyalgia in its true sense was not myofascial pain syndrome even though many people confuse the two. We embarked on this journey together and over the course of a couple of decades reaching out to the world experts at the time in fibromyalgia reading every single peer-reviewed publication that was out there looking at every textbook chapter. We sort of became experts on our own on this and then we started publishing and researching ourselves and over many, many years seeing many, many patients with at least the fibromyalgia label, if not actual fibromyalgia.
I had this couple of decade-long experience both academically and research base but also, clinically and we published a lot to try to clear things up with our colleagues as health care providers but the latest foray with the Fibro Fix summit and then the Fibro Fix book was really to take the story to the streets as they say, to the people that really have it or think they have it and make them more educated about it so they can be of their own best health advocate and navigate this health care system which really doesn’t do a great job with these patients with fibromyalgia or those who think they have fibromyalgia.
K. Fitzgerald: Yeah, absolutely. I just wanted to recommend to people listening, again, you can go into this podcast page on my website and actually pop open the Brady, Schneider and Pearl paper in JMPT which was published in 2006. I know 2006, it’s a decade-old paper but arguably, it’s really the most comprehensive look at the condition and if you scroll to Appendix A in this paper, you’ll see some of the concepts that we’re going to be talking today so you can just track along with us.
David, I know it’s a remarkably expensive issue and I was in the pain clinic as you know, advanced diagnostic pain treatment center over at Yale New Haven, and we were training treating “fibromyalgia.” It was the garbage can diagnosis. As I was reflecting on our talk today I was thinking back to those years and I would see plenty of patients with this particular label and we gave them opiates. Well, I didn’t. I was practicing naturopathic medicine, but they were commonly on poly pharmacy, opiates, psychotropics, anti-seizure meds, muscle relaxants, et cetera, et cetera.
It was really challenging to see how debilitated they were and how over medicated they were but obviously, they needed them and there were still breakthrough pain because we didn’t have this functional,. aActually, yeah, I had some nice outcome perhaps so we can talk about some of that later but you’re going to cover it. In the mainstream medical model it’s polypharmacy and it continues to be polypharmacy regardless of what fibromyalgia is, without understanding the complexity of it.
Can you, let’s just move into that, define fibromyalgia and then talk about how it’s diagnosed and then we’ll just move through some of the evolution of your thinking in a more detailed way.
Dr. D. Brady: I mean fibromyalgia grew up as a disease or a disorder, if you will, back in about 1987 when it was first issued in ICD-9 code at the time so it became a real entity because now there was third party billing potential for it and that actually made research dollars flowing to it where before there was really a scant amount of published research and indexed journals and then, it really exploded in 1987. That created a real need or desire for a formal diagnostic criteria which first was published by the American College of Rheumatology or ACR in 1990.
It was further modified or substantially modified in 2000 and then in 2010 a whole new criteria came out, modified again in 2011, and then just recently hot off the presses we have the brand new ACR criteria of 2016.
They all really center around some common principles and that is for some that we diagnosed with fibromyalgia, it needs to be not a new condition, it needs to be chronic so it needs to be three to six months or born duration. You need to make sure that there’s no other medical condition that would explain the person’s symptoms and that can include one or more medical diseases or conditions that might be ganging up on the patient creating all of the normal symptoms of fibromyalgia so it is a diagnosis of exclusion which many clinicians seem to forget along the way.
It really centers around some major elements and that is the person’s main symptom that they would say with their most troubling situation would be unrelenting body-wide achiness or pain. It’s a pain that is described usually as a achiness so adult ache, not a sharp, shooting, radicular type of pain and it has to be global in that it really needs to be all over the body, above the waist, below the waist, left side, right side, along the midline, out in the periphery. It has to be everywhere, it can’t be regional or localized pain syndromes and that includes multiple regions of the body.
It needs to be a phenomenon that’s occurring without discrimination around the entire body and that’s another place where a lot of clinicians miss the diagnosis or they lend toward over diagnosis because they don’t make sure that it is truly global pain, not focal pain due to some somatic problem in the muscles, joint, ligaments, soft tissues, et cetera. Also, along with this unrelenting achiness around the body is the fact that virtually 100% of these patients have long-term persistent fatigue.
Now that doesn’t mean the disease should be confused with chronic fatigue syndrome because you often hear them mentioned together, chronic fatigue/fibromyalgia which is a falsehood and misnomer that needs to cease but it started happening about 30 years ago and it’s never stopped. These are vastly different disorders with entirely different diagnostic criteria, so they are not one in the same. They should not be comingled in the way that they commonly are.
The other thing about fibromyalgia, which is different than chronic fatigue syndrome as well, is that there’s a whole host of what we call central sensitivity syndrome type of problems related to hyper vigilance. You see things like for instance a strong association with irritable bowel syndrome, so vague gastrointestinal problem, irritable bladder, basically irritable everything. These patients are in a persistent state of sympathetic dominance and really an imbalance in their autonomic nervous system.
Along with that, they have other centrally mediated issues such as anxiety, depression, cognitive dysfunction, so called fibro-fog, and they have a very specific type of sleep dysfunction where they get what’s called unrefreshed sleep. Even when they sleep 10, 12, 15 hours they wake up and feel like they never slept so they’re not restored or regenerated through sleep.
It’s a really interesting phenomenon. Once you get used to all of these hallmark elements of the disorder, you quickly find that the vast majority of people who come in and say they have fibromyalgia or someone has told them they have fibromyalgia, it could be a physician, it could be their neighbor, it could be Dr. Google, it doesn’t matter, the vast majority of them actually do not meet the criteria and do not have classic fibromyalgia. They definitely have things wrong with them, they’re just things that are commonly being mislabeled as fibromyalgia and many of these things are the things that would mostly likely be picked up by a functional medicine doctor and are very hard for the conventionally trained physician to understand because they’re just not trained in that model of care.
K. Fitzgerald: Right. How do you diagnose a true fibromyalgia? I mean I’m assuming that you’re paying careful attention to the irritable everything presentation on your intake. Is it mostly clinical? Are you looking at labs for this? Let’s just talk about true classic fibromyalgia right now and then we’ll expand beyond that and look at some of the fibro mimickers in a minute.
Dr. D. Brady: Okay. Well, you know, Kara, it really goes down to medical diagnosis 101. It’s no different than any other disorder in that it really centers around first doing a really good history and intake with the patient, hearing their story, and we’ll talk about what elements you’re looking for there in a moment. It requires a good physical examination and assessment and then you need to finally turn to laboratory and imaging and those kinds of things in any medical diagnosis. In fibromyalgia what you’re looking for in the history, first of all, the vast majority of these patients will be females.
The two most prevalent things that lend toward a diagnosis of fibromyalgia is being a woman and getting older. The
vast majority of these patients and I mean way above 95% are female and they are somewhere between the age of, let’s say, 30 and 60 at diagnosis. Certainly, you could be younger, you could be older, you could be male but it’s the exception, not the rule. The other thing in the history is you want this clear history of global pain so when you ask the patient, “Okay, where does it hurt?” If they start saying, “Oh my shoulder, my hip,” if they start saying that their joints hurt that’s not fibromyalgia because fibromyalgia is not an articular disorder. You start looking for more degenerative joint disease or some sort of inflammatory autoimmune arthritisty or something like that.
You want the main pain being perceived in the softer compliant tissues, muscles, fascia, ligaments, tendons and so forth, and you want it to be everywhere, not in a couple of places. You also want to listen for the history of those concomitant elements of anxiety even panic attack, at least mild depression, mind-racingraising inability to go to sleep and then once they are asleep when they wake up they don’t feel refreshed from sleep and then a history of some level of cognitive dysfunction and irritable bowel syndrome so gas, bloating, constipation tends to be the rule but they could get alternating constipation and diarrhea. The more of those boxes they check, the more likely they actually have a central pain processing disorder like fibromyalgia and not some other condition.
In the examination you need to do just a good nuts and bolts physical exam to make sure that there’s no other medical issues going on but I still am an advocate,. nNow I don’t do those 18 specific points that were in the original diagnostic criteria and no longer are, but I do challenge the person with some firm digital pressure into major areas of muscle bulk. I may push into their anterior thighs and their posterior thighs. I may squeeze their gastroc-soleus, I may squeeze their upper arm, their forearm, challenge different areas of the body to satisfy for myself that they actually have a pain response all over, globally to a level of pressure that in the normal person would only be interpreted as squeezing or pressure and not pain.
Then finally, from the laboratory standpoint it’s a diagnosis of exclusion so you have to do the nuts and bolts of rule-outs. You have to rule out organ failure, undiagnosed malignancy, MS, inflammatory conditions. A complete blood count, a basic blood chemistry profile. Usually, we are doing a granular thyroid panel with not only TSH but both total and free T4 and T3. We’re looking at thyroid antibodies on the first path and if the patient is particularly complaining of some perception of pain in the joints as well we’re usually adding on maybe a rheumatoid panel or an arthritis panel but usually, at a minimum we’re doing global markers of inflammation like CRP, sed rates because classic fibromyalgia is not a systematic inflammatory disorder.
I know doctors are trained to think of pain as being inflammatory driven. Not all pain is driven by inflammation or by tissue insult. The classic pain that we deal with all the time tends to be due to damaged, irritated tissue and inflammation but this is a different kind of pain. It’s not a neurogenic pain. It’s a different kind of pain. It’s what they’re now sometimes referring to as third pain. It’s a third type of pain that is more deep in the brain, centrally-mediated pain perceptual issue. So iIt’s not amenable to anti-inflammatories, even steroids and ironically enough, even opioid pain relievers don’t tend to appreciably change this type of pain of classic fibromyalgia.
Using the laboratory to rule out a lot of other medical conditions is important but when we start screening for some of these things that masquerade as fibromyalgia, we start getting into the metabolic or functional lab testing realm and we use a lot of organic acid testing and we can talk about what we look for on there if you want.
A lot of times we are also doing more molecular GI testing, looking at the GI microbiota and seeing if there’s disruption and problems there. Really trying to put a whole comprehensive clinical case together on this patient and find out are there metabolic issues contributing, are there organic medical issues contributing, are there musculoskeletal problems that need a physical medicine approach or is this really a centrally-mediated pain processing disorder?
K. Fitzgerald: Thank you. That’s very useful. Basically, all of these standard labs that you’re going to be running are normal or fairly unremarkable, right? Maybe perhaps from a functional perspective you might see some abnormalities. Now, just for your standard workoutwork up, are there any labs that you might see trending or is everything really basically going to be okay? Not including specialty stuff.
Dr. D. Brady: Yeah. That’s a great question. You always have to understand that the patient has the right to more than one disorder at any given time so the minute you find something doesn’t necessarily rule out everything else. What I do see in a lot of the patients who come in who say they have fibromyalgia or they may have been diagnosed even at a rheumatology center of excellence with fibromyalgia or for some reason they think they have fibromyalgia.
Within that total population I see a lot of thyroid dysfunction, right, a lot of low T3 syndrome kind of stuff where they don’t convert from T4 to T3 or they have excessive reverse T3 or in some way, shape or form they have underperforming, if not overtly abnormal thyroid function. I see a lot of low ferritin and serum irons. I will often see some level of evidence of chronic [inaudible 00:23:26] stealth-viral infection going on irritating the immune system whether it’s EBV, CMV, one of those sorts of ubiquitous viruses, if you will. When you get down to actual people who truly have classic fibromyalgia meet that diagnostic criteria, a lot of that melts away but not all of it.
Even the patients who have classic central pain processing disorders I personally find that a tremendous number of them have suboptimal thyroid function and they do respond symptomatically and clinically if you optimize that. That’s not a big surprise though because so many females in general have that going on and so that’s something I always look for. Generally, the classic fibromyalgia patients do not have evidence of a lot of systemic inflammation so they don’t have CRP. They don’t have ESRs. If you look for really micro levels of inflammation you may find that. That’s the patterns we see.
Now, we also on functional testing, for instance, generally see a lot of patterns related to suboptimal energy production or ATP production at the level of the mitochondrial biochemistry but what does unmask very frequently in classic fibromyalgia in organic acid testing is imbalances in neurotransmitter metabolites, particularly the catecholamine ashes like vanillylmandelic acid or vanillylmandelate or VMA and HVA tend to be on the high side and their serotonin markers like 5HIAA tend to be on the low side. That’s the classic pattern although not everyone conforms to that pattern.
K. Fitzgerald: Okay, that’s really helpful, David. Listen, I just want to just circle back to a few comments you made. First of all, folks, I wanted to just hit home again that David said that trigger point or tender points are no longer part of the diagnosis and he’s not using them. I think it’s important.
Dr. D. Brady: Now, that’s tender points, Kara. Tender points, that’s another point I want to clarify. Tender points have often been … The name trigger points and tender points have been used interchangeably and they’re very different things.
Trigger points are associated not with fibromyalgia but with myofascial pain syndrome through problems in the muscle where there’s that focal palpable knot of the trigger point and the taut bands out toward the origin and insertion.
They’re very tender when you push on them. They can cause a very defined referred pain pattern defined by Travell, Simon, Nimo and others when you hold pressure on them.
That’s very different than the tender point of fibromyalgia where there is really no palpable knot in the muscle.
The muscle feels normal, looks normal. The biopsies are normal. Everything is normal. It’s just when you push anywhere on the muscle, they hurt. They’re tender points.
That’s a big differentiating point but the tender point exam which was those 18 points first put out in the original ACR criteria. Now no longer are you instructed to actually do the tender point index with … You’re supposed to do it with this pressure algometer. Nobody had those to specific amount of pressure into these 18 points but those 18 points were kind of ridiculous because a lot of them were areas where everyone hurts just if they work on a computer, drive a car, postural distortion patterns.
They were areas like the suboccipital muscles where the cervical muscles hold your head up all day or the upper trapezius muscles, very common points for trigger points. The upper lateral aspects of the forearm like the tennis elbow area where everyone hurts. The gluteal muscles where everyone hurts.
That was really fallacy. Now there’s a subjective questionnaire to ask patients whether they hurt in all these different areas of the body. I still do a physical examination where I challenge the body to see if there’s an excessive pain response to digital pressure but I don’t conform my exam to those 18 defined points. In fact, I avoid many of those points and I instead go right to the heart or the middle of the large muscle groups.
That’s very, very instructive to me so I think that should still be done. The rationale for pulling it out of the diagnostic criteria to me was ridiculous. It was that physicians are no longer trained how to do competent hands-on examination. Rather than pull the competency up they just took it out of the diagnostic criteria. They realized that modern physicians are really good at ordering MRIs and functional nerve velocity studies and all that stuff but they’re just not very good at putting their hands on people anymore.
K. Fitzgerald: That is funny. Geez. Okay, well, thank you, thank you, thank you for that clarification. I have two more quick … Actually, I have three quick questions I want comments on and then I want to dive back into just what we’re thinking about with treatment and diagnostics and so forth.
First of all, why are we seeing this in women primarily? I’m sure you’ve thought about it. What are your thoughts on that?
Dr. D. Brady: Yeah, I mean we don’t definitively know but there are a lot of hypotheses out there. Fundamentally, the male and the female brain, now we’re generalizing here, there are certainly outliers to this, exceptions to this. The male and the female nervous systems seem to react differently to stress, particularly ongoing chronic stress at a high level and particularly when the subject is exposed to those stressors at an early age when the nervous system is still very neuroplastic, very malleable and is sort of learning how to cope with its environment.
If young females are put in environments for instance with very, what I will call, rocky circumstances in their upbringing, this could be let’s say an alcoholic or a substance-abusing parent, an abusive parent, or just really super outrageously high expectations on the part of the parents that the child can never feel like they can possibly measure up and they’re made to feel like that. Certainly, if there’s verbal abuse, physical abuse and most notably, sexual abuse going on, both the male and the female is damaged by that but they seem to react to that in a different way.
There’s an inordinately high level of what we call adverse childhood events in the histories of women who have classic fibromyalgia. It’s not uncommon to hear histories like yeah, my parents went through a divorce, my father was a very authoritarian alcoholic. He used to beat my mother or used to yell at us. We were afraid of him. If there’s ever a situation where there’s a feeling of lack of safety or a threat physically while the person’s growing up, their nervous system seems to get into a persistent state of hyper vigilance, waiting for the next disaster, the next shoe to drop. Over time, it gets almost locked in that kind of pattern at the most primal level, at the level of the limbic system and deep centers of the brain.
In females, particularly, if they’re then subjected to stressors later in life, it can almost reactivate or elevate that dysfunction of the stress response to the point where they develop clinical issues such as irritable bowel syndrome, anxiety, panic attack, insomnia, and the most profound example would be full-blown classic fibromyalgia.
The males who are in similar circumstances do not generally go on to develop those kinds of disorders but they do go on to develop patterns of very easy to frustrate, acting out in violence and frustration. They tend to be repeat abusers in the way that they may have been abused. Females do not tend to do that. We’re very different in the way we respond to those things. It’s not fully understood why that’s the case but it’s certainly pretty predictably observed.
K. Fitzgerald: That’s so fascinating. It seems almost like a description of testosterone versus estrogen to incredibly simplify it.
Dr. D. Brady: Yeah, that’s been looked into. They’ve never made any firm correlations in the role of estrogen and testosterone and so forth although, like I said, there’s a strong correlation with underperforming thyroid and these disorders, it seems like. Although independently that can cause a lot of the symptoms associated with fibromyalgia and lead to erroneous diagnosis. There’s a strong amount of overlay or comorbidity with classic fibromyalgia and underperforming thyroid and of course, we know that females are much more susceptible to that particularly of the autoimmune variety like Hashimoto’s and Graves.
Interestingly enough, the males who get Hashimoto’s much, much less than females but the males who do get it tend to be the males with the high estrogen levels. There’s been a lot of different ties to estrogen and autoimmunity through various mechanisms that we don’t really have time to get into today.
It’s a complex business. There’s a lot of interconnections here that are not … There’s a lot of associations understood. There’s not a lot of causal mechanisms understood in some of these interesting questions.
K. Fitzgerald: I appreciate that and it actually answers what I was going to just ask you for the follow up which is what would we look for on family medical history and past medical history and I think you’ve outlined a lot of it. It seems almost like it’s a PTSD type of presentation.
Dr. D. Brady: Yeah. I think that’s a great observation because it has been described as exactly that. The central nervous system dysfunction and the neurotransmitter dysfunctional pattern seen in classic fibromyalgia is really seems to be a variant of exactly what you see in overt posttraumatic stress disorder and most people think a PTSD is something that people experience after battlefield experiences or rape or some really, really horrific acute event. That’s not really a full comprehensive understanding of PTSD. There are variations of PTSD and Peter Mole has done some of the best work on this when he talks about adverse childhood events and adverse life events can cause a lower level PTSD type of presentation and full blown PTSD.
It’s almost like, if I can make an analogy, it’s almost like gluten or non-celiac gluten sensitivity versus celiac [inaudible 00:35:13]disease, like shades of grey.
K. Fitzgerald: Yeah, absolutelyabsolute … It’s really, really useful.
Now, listen. I got to just circle back. I alluded to this earlier. Are you using a specific intake for your fibromyalgia patients or do you have one created? I mean I know that clinicians listening to this call would be highly interested in it or are you just using your standard?
Dr. D. Brady: Well, I use my standard functional medicine patient intake question. The full packet, I ask a lot of questions about a lot of things. I use the metabolic screen questionnaire emanated from the Institute of Functional Medicine a long time ago. I do use that. In addition to that, in anyone who’s coming in complaining of a chronic pain syndrome and anyone who thinks they may have fibromyalgia … Now I don’t think this is the greatest criteria and it’s not the end all be all, but I do use a patient questionnaire version of the 2011 modification of the American College Of Rheumatology Diagnostic Criteria which involves a pain diagram where you have the body, front and back, and a bunch of checkboxes in anatomical areas where they check whether they have significant pain in those areas over the past several weeks.
That’s a subjective questionnaire on paper of where do they hurt and do they hurt all over or just in certain areas.
Then there’s specific questions related to a lot of these concomitant symptoms such as fatigue, irritable bowel syndrome, headache and so forth, and then a cognitive dysfunction memory issue. Then it asks a couple of questions on has this pain been or have these symptoms been present at their current level for at least three months then you have to answer yes. Do you have a medical condition that would otherwise explain theseis conditions, the person has to answer no. That’s a questionnaire that’s available out there on the net. I provide it to people in my seminars. That’s in my book.
It’s actually on my website. If you go to fibrofix.com on your resources, I think it is, you will find some of these questionnaires and other things that I use and certainly you’re welcome to use the diagnostic questionnaire associated with the ACR 2011 criteria. It’s free use.
K. Fitzgerald: Okay, perfect, all right. We’ll actually link to that specific page in addition to giving the other two websites. Now, listen just really quickly because I want to jump in to treatment and I want to talk a little bit more about the specialty labs. Just snapshot difference between fibromyalgia and chronic fatigue. I know those have been linked up forever. I just think that we’re starting to separate them out and certainly a big reason why we’re doing that is because you’ve been educating on this pretty tirelessly to our community. I think our community is beginning to tease them apart. Just give me a thumbnail of the difference of the two conditions.
Dr. D. Brady: Yeah. Well, I’ll start out just by saying that it is true that patients with true classic fibromyalgia have almost 100% correlation with ongoing persistent fatigue. Therefore, by loose definition they have chronic fatigue but it’s not what it’s is being talked about when they say chronic fatigue syndrome.
Chronic fatigue syndrome is really something that started being appreciated many decades ago but it was first associated with often a history of … It came on after an acute viral-like illness, like a flu type of illness. Therefore, the person’s acute flu-like illness resolved by they never quite re-attained their level of vitality and energy and so forth that they once had. When they look into various immune markers looking at lymphocyte subset and CD ratios and all that, they found out that they have persistent immunodysfunction, immune deficiency, that’s where you got something like CFIDS, chronic fatigue and immune dysfunction syndrome.
That prompted research into what viruses were responsible and it is true, you see a whole lot of people who seem to have persistent immune irritation with Epstein-Barr, cytomegalovirus, HSP, HTLV-1 and others as potentially at least part of the picture of their persistent chronic fatigue syndrome. The diagnostic criteria for a chronic fatigue syndrome really includes the fact that if you ask that patient what is their most pressing issue or concern they would say the unrelenting fatigue. If you ask them about anxiety, unrefreshed sleep, pain all over the body, IBS, you don’t nearly get the kind of correlation between chronic fatigue syndrome that you with fibromyalgia.
Conversely, in fibromyalgia the most pressing symptom that the patient will almost always tell you is the pain, the fatigue is secondary. The way their brains behave are very different. In chronic fatigue syndrome these patients are usually … If you look in their stress response they tend to have a lower flat line cortisol. If you do a salivary cortisol test, for instance, and look at the four points throughout the day they tend to be persistently low. If you do organic acid testing and you look at the adrenal medullary products like the catecholamine or adrenaline, epinephrine, norepinephrine, even dopa, those markers, those metabolites tend to be low. They under produce the catecholamines. That’s why they’re so fatigued. They can’t even get off the couch. I mean they generally are noon panic attacks and anxiety they don’t have the energy for a panic attack.
The fibromyalgia patient is different. They tend to if you do check salivary cortisol they have this low cortisol levels, the classic of long-term adrenal stress but they tend to have a compensatory pattern of elevated adrenal medullary product. They’re over catecholamine producers, epinephrine, norepinephrine and so forth, so that’s why they have a tendency toward things associated with high adrenaline output like a sympathetic dominance, a hyper vigilance. You get anxiety. You get panic attack. You get things like that, a racing mind where they can’t enter stage three and four delta wave sleep which is the restorative sleep. They have these alpha waves that are more associated with a relaxed waking state even in their deepest times of sleep. When they should have delta waves they have alpha waves. It’s called alpha wave intrusion. They never really shut the brain off. They are always on guard, if you will.
It’s a very different pattern. They really are inherently very different entities. They just got attached a long time ago sort of like glucosamine and chondroitin sulfate are always talked about in the same breath. Why? Who knows but they are. It’s just the way it is. It’s a hard thing to break.
K. Fitzgerald: Well, you’ve just done such a great job clarifying it. I mean, really, if I summarize in the most simplistic way people with fibromyalgia are in a lot of pain, that’s the chief complaint. Chronic fatigue, they’re really tired. Then of course, we have all this richness that you’ve just … You’ve colored it in to a good extent and folks, the transcription for this podcast is available so you can scroll through and get all of these myriad pearls that Dr. Brady has given to us.
Let’s circle back to just finishing up on the labs. You talked about organic acids. You’re going to see evidence of mitochondriopathy, central energy pathway compromised, and then you also see the elevation of the catecholamine metabolites and …
Dr. D. Brady: I want to point out though Kara for that, a lot of people say oh my, fibromyalgia is just a mitochondrial dysfunction. That is not proved out to be the case. You do see usually it’s not uncommon even a classic fibromyalgia patient to see some level of sub-optimal energy production. It does not appear to be the major issue. Muscle biopsy and functional physiology studies of various stripes in the muscle tissue of classic fibromyalgia patient does not suggest a significant mitochondriopathy although mitochondrial down regulation and energy production problem is a major cause of fatigue and can definitely result in muscle achiness.
I because if you just think of, let’s say, a temporary mitochondriopathy, g.
Go out and run a bunch of sprints or do some exertional activity that you’re just not used to and that you’re not at a level of fitness or acclimated to. You will have a couple of days where you may be tired but your muscles are achy because of that buildup of lactic acid and other acidic metabolite because you just couldn’t sustain enough oxygen for that level of demand and energy production so your body went into anaerobic metabolism in the Cori Ccycle trying to generate a little bit more energy and it takes a couple of days to clear that stuff out. Once you reinstate enough oxygen, you get out of oxygen debt. These people who have mitochondrial disorders or it could be cause by profound iron deficiency.
They’re not carrying oxygen on the red blood cells to fuel the mitochondrial furnace or they have respiratory problems or whatever it may be the cause. If they’re not making a bunch of ATP in the mitochondria they will stack up and they will rely more on anaerobic metabolism and they will get energy deficiency because they’re not making a lot of ATP. Their brains don’t work very well because there’s not enough ATP so they have so called fibro-fog and their muscles will build up a bunch of acidic waste products. If you go mashing on their muscles with pressure that those acidic waste products will hit free nerve endings and they’ll get a pain response.
If it’s a woman who’s middle aged and has that going on she’s undoubtedly going to get a diagnosis of fibromyalgia even though there may be no anxiety, no depression, no IBS, none of that, it’s a common masquerader of fibromyalgia.
It could be some level of mitochondrial dysfunction that’s associated with the classic fibromyalgia or it could be the primary reason why they have the symptoms that they have and that’s where the therapy really needs to be directed.
K. Fitzgerald: Yeah, okay, perfect. Again, that’s really helpful. I see just looking at organic acids for years now and thyroid, full thyroid panels, I tend to see both of those, central energy and suboptimal thyroid track with any chronic disease that’s been around a long time.
Dr. D. Brady: You’re right, exactly. That’s the perfect statement, you’re correct and particularly in women. It’s just I think thyroid underperformance is so prevalent in women today as they age and start getting into their late 30s and to their 40s. the more stress, the worse. The more children they’ve had, the more stresses on the system, the worse their GI microbial pattern is. There’s molecular mimicry. There’s all kinds of stuff, the worse they eat.
I mean as we know it’s a complicated issue. If thyroid is suboptimal that’s the metabolic set point and that has control over a lot of the biochemistry including in the mitochondria so everything is going to slow down. It’s easy to get a lot of crossover stuff in all this. It really takes a good, astute clinician to know how to triage all this stuff and know where to direct the primary attack, if you will, with your therapeutic intervention.
K. Fitzgerald: Yeah, absolutely. All right. Let’s go ahead and comment on some of the other specialty testing you’re using. You mentioned stool testing and anything else you might look at and then we’re going to go head long into treatment. What else do you have?
Dr. D. Brady: When people have a lot of gut issues that would be usually classified like IBS we still want to look for organic reasons why that may be occurring. We really have to look at the GI environment. As you know and just as a matter of disclosure I’ve been very involved in the laboratory industry over many years including being a consultant on the development of various GI-based test and the latest venture in that is with the GI map which is a third party validated Luminex-based molecular mapping of the GI microbiota for clinically significant and actionable organisms.
Pathogens, opportunists as well as beneficial organisms, so with a real eye toward the opportunists that tend to be associated with or are associated with autoimmune diseases. Klebsiella, Citrobacter, Proteus, Yersinia are related to autoimmune thyroiditises, autoimmune arthritises, I mean you name it. We try to rule that stuff out, clean up the gut environment as much as possible.
David Perlmutter had talked a lot about dysbiosis creating metabolic load andin LPS and other types of things that in the face of hyperpermeability of the GI mucosa can create a gut-brain access, leaky gut, leaky brain, vagus nerve transmission, all that stuff which can create somewhat of a brain on fire syndrome and inflammation deep in the brain. We see this in some studies of fibromyalgia patients where they have upregulations of some cytokines associated with glial activation in the brain.
This could create a deep-seated inflammatory brain pain even though the patient is not overtly inflammatory. Now, whether that explains classic fibromyalgia I have serious doubts about that. I think that’s a subset of people who have pain, fatigue and other things related to this gut-brain access issue. Everybody tries to make anything that is found that creates pain and fatigue, oh, that’s the reason for fibromyalgia. I think this classic fibromyalgia is a different animal than a lot of these metabolic reasons because the gut-brain connection doesn’t explain why it’s mainly female, it doesn’t explain necessarily the anxiety, depression, and other things. It is something certainly to look at and I think just fundamental to dealing with anybody with chronic illness we have to test, look at, optimize and correct anything going on in the gut that’s not good.
We use the GI map from Diagnostic Solutions Lab. If you want to learn more about that read the white paper. You can just go to diagnosticsolutionlab.com. There’s a lot of information about that.
The other specialty test I may use is we have to rule out, particularly I practice in Connecticut so I’m always trying to rule out particularly if there’s articular and neurological stuff going on that seems to align and stuff in the history, we’re trying to rule out Lyme but not only Borrelia but co-infections with a lot of the other organisms as well. While we will do western blot and look at the different bands and so forth, often if we’re still suspicious, we will turn toward other testing like Lyme and co-infection PCR testing or even Lyme cultures and sometimes cytokine pattern analysis such as an iSpot type of test.
K. Fitzgerald: Okay, perfect. Now, I’m sure that somebody is thinking about the role that molds might play. I mean are you ever looking at mold exposure, mycotoxins in your investigation in short?
Dr. D. Brady: It’s something to consider, particularly if the history suggests that and where they live and so forth. I tend to then will refer that out to people who are more skilled in that than I. I am not a specialist in mold toxicity and the best practices for testing and treating and so forth. I tend to send that to folks who are a little bit more astute with that than I but it’s certainly always a consideration as are heavy metals and any other toxic burden that may be playing a role.
K. Fitzgerald: Perfect, thank you. You’re casting a pretty wide net. We’re going to go as we move into treatment the last question on the lab front which will segue into treatment is, are you looking at food reactions? I mean I remember one of my “fibromyalgia” patients at the pain center was just an undiagnosed celiac patient.
Dr. D. Brady: Yeah.
K. Fitzgerald: Pulled her off of gluten and boom, she was able to taper off of her myriad medications and get on with her life relatively quickly and it was a big miracle and a big deal at the lab or not at the lab, at the clinic. Talking about food reactions, I’m sure you’re looking for celiac, you’re looking gluten sensitivity and what else might you be doing there?
Dr. D. Brady: Yeah. We do particularly if we’re suspecting any kind of inflammatory condition upregulation of the innate immune system related to any kind of autoimmunity driving their pain. It’s essential that we look for the environmental triggers that fuel that. It’s always something is irritating their immune system and often they need the genetic propensity with the right HLA pattern and all that kind of stuff and the hyperpermeability, leaky gut and so forth. There needs to be an environmental trigger and that sometimes that’s aberrant microbiota. It could be bacteria expressing certain peptides in the gut and so forth. It could be chronic viruses but quite frequently, it’s food. It’s the stuff we put in our plates every day.
You to need to look not so much for food allergy in the sense of a true allergy in IgE mediated like an immediate atopic reaction, anaphylactic reaction. That’s not what we’re generally hunting down. I’m looking for what foods activate that person’s innate immune response so inflammation basically.
The test I find most useful in doing that and it was just validated significantly in both a clinical and a mechanistic study just up the road here in Yale is the ALCAT test which looks at … I mean that test has been poorly understood for a long time because people try to align it with IgG test or IgE test or other “food allergy or sensitivity tests” and really what it is, is not that. It’s really a test looking at what activates your white blood cell population and creates degranulation, creates cytokine patterns associated with innate immune reactions or inflammation and that’s what that does. It’s a referendum on that.
We utilize that type of testing quite frequently to try to get people off diets that are clearly not agreeing with them from an immunological standpoint.
K. Fitzgerald: Okay, all right. Well, as you probably know I’ve had some questions on ALCAT. If Yale’s just on done a solid research on its study and I’d definitely appreciate seeing thate publication.
Dr. D. Brady: There’s really good research from all over the world at different academic centers. I think the problem has been I think partly on the labs messaging which is it was positioned initially as a food sensitivity, food allergy test. In reality, they use that modified culture counter technology to assess the immune response to way more than foods. They look at herbs, drugs, food additives, molds. It’s really not a food sensitivity test at all in the classic sense and it doesn’t align you in IgG test which is an entirely different phenomenon. It is really, I like to call it, an innate immune response test.
When you look at it from that perspective and you evaluate it on that perspective your opinion generally changes of it. If you’re trying to do split samples with an IgG test, for instance, it’s not going to align, it’s just not.
K. Fitzgerald: Okay, all right, that sounds good. Well, listen when they publish that Yale paper, keep me in the loop because I’d really like to see it if they have anything like that.
Dr. D. Brady: It’s been put out an abstract already from presentation at a major conference but it’s in final review right now, both at PLOS ONE and I think at JAMA so let’s see.
K. Fitzgerald: Okay, wow. Okay. All right, keep me posted. Let’s move on to treatment in our final minutes here. What are you doing with these patients clinically for treatment?
Dr. D. Brady: We’ll take the classic fibromyalgia patient. The patient really has this. It’s really a multi-front approach. You have to deal with … if they had significant abuse, sexual abuse, physical abuse, verbal abuse that their nervous system has really never got over, we deal with that and the hyper vigilance in several ways. One is I’m lucky I have a practice partner who’s very skilled in functional EEG and we’ll do EEG studies on them and look at their brain wave patterns in the waking relaxed state.
We’ll run them through different cognitive behavioral protocols using real time EEG with audio tones and different tasking and things that allow them to learn how to change their brain wave patterns to a more calm state or more normal state, which also helps them get into better sleep states when they sleep. We transition them over to not be dependent on an in-office EEG system but we’ll move them over to something like a HeartMath, like heart rate variability, application on their iPad or iPhone or something like that for just cognitive behavioral therapy.
A lot of times we’ll find out what resonates for them and get them doing mindfulness meditation or some calming, low, not vigorous yoga but more stretching, mobility, relaxation yoga. Also, sometimes just deep breathing exercises, guided imagery, prayer, whatever really works for them particularly in the evening as they’re preparing for bed. We work with their sleep hygiene off of the electronic devices late as night. I spoke at IFSM this past year on this exact topic of sleep dysfunction and fibromyalgia and global pain and we talked about a lot of the different approaches toward better sleep and sleep hygiene working with the environment of their sleep, working with their circadian rhythm and such things like that.
If necessary we send them to … I have a couple of counselors, psychologists and counselors who are really versed in this hyper vigilance PTSD almost variant type of issue. They will work with them. Some of the new trends are not to go revisit the abuse and the issues, picking at the scab but finding techniques to move beyond it. They call it forgiveness therapy a lot. It’s not necessarily implying that you forgive someone who may have horribly abused you.
Sometimes that person is now an elderly parent or a family member. They’re very different now. There’s an opportunity to forge a new relationship with them. They will be even apologetic about it and there’s a lot of therapeutic value in coming to a new mind space about that for the victims.
Sometimes that’s not possible, maybe they’re deceased, maybe they’ve never changed at all in which case you still have to come to a place that’s forgiving and moving on within your own psyche.
From the biochemical side we really zero in on some of the known aberrant patterns and one of them is these patients with classic fibromyalgia have persistently low central serotonin and even enteric serotonin. We try to do things to get their serotonin levels up including precursor therapy like 5-hydroxytryptophan is what I use the most combined with things like melatonin at night and threonine and calming botanicals like German chamomile and ashwagandha and phosphatidylserine, things that calms the stress response or adrenal tonics. I’m sorry. They’re adaptogens but they’re not stimulating. We don’t use panax ginseng. We don’t use rhodiola. We don’t use licorice. We don’t use those things that are more appropriate of someone who has low catecholamines. We stay away from anything that’s stimulating and use things that are calming but are adaptogenic, things that help get you into better stage three and four sleep.
Some 5-HTP at night with melatonin and sometimes a little bit of GABA, PharmaGABA. We use chewable PharmaGABA frequently for anxiety, panic attack, and we generally will support mitochondrial function if there’s any problems there at all with things like therapeutic levels of a very good bioavailable coQ10, some ribose, maybe some higher dose carnitine, nicotinamine riboside or that novel form of nicotinamide that can be very helpful in mitochondrial dysfunction.
Finally, we need to get these patients moving again. In my book, The Fibro Fix, I do this whole 21-day upfront foundational program where while they’re reading and trying to figure out by answering questions different gateways in the book and so forth, do I really have classic fibromyalgia or do I have one of these other masqueraders and if so, which bucket of masquerader am I in and how do I address it. While they’re trying to figure that out, we’re just running them through a comprehensive 21-day detox elimination diet. Not that that’s a cure for fibromyalgia but it’s just metabolically resetting them, getting them prepared for recovery.
If there is any inflammatory issues driving their pain and issues that’s helping with that, taking the heat off their immune system. Part of that is also calming practices like we talked about but the third element is getting them moving again. The body has to move, structure and function very dictated or very related so you have to get the functionality back by moving the body but that doesn’t mean exertional exercise.
In my book and on the website in the resource page there’s a whole expanded exercise movement, self-treatment guide that gives exact pictorial instructions and things on how to move, how to regain mobility, range emotion without taxing the person metabolically to where they feel like they got hit by a train but it’s really important to get them moving again. We attack it with all those different ways. If there’s thyroid issues we deal with those too. If they also have myofascial pain syndrome we do some physical medicine. We basically treat them as an individual on what we find.
K. Fitzgerald: Okay. Well, I just really appreciate all that you’ve given us today, Dr. Brady. I mean your expertise in this area, it’s very apparent. I again encourage folks to look on the website. You’ll see the papers Dr. Brady referenced and we’ll link over to his site.
Dr. D. Brady: Yeah, Kara. If they just go to fibrofix.com and then they’ll see a tab along the top that says resources. It will give not all of my paper certainly but some of the more seminal papers. There’s three of them listed there. Then on the bottom there is the questionnaires and guides we’ve discussed. There’s the electronic interactive version of the metabolic screen questionnaire, if they don’t have that. There’s the ACR diagnostic criteria questionnaire I referred to, if they don’t have that. There’s also that diagnostic reasoning guide that I had in one of my papers. There’s also a much more comprehensive algorithm of how to work up a patient in that 2006 paper in JMPT and there is a link to the expanded exercise and self-treatment guide.
K. Fitzgerald: Fabulous.
Dr. D. Brady: All right.
K. Fitzgerald: Well, we’ve gone, yeah, we’ve gone over but I think it was really worth it. Thank you so much.
Dr.D. Brady: Great. Well, I hope it’s helpful and good luck everybody out there. These are not easy patients to deal with necessarily but instead of that almost assumes frustration and oh no, another fibromyalgia patient. If you take a look at some of these resources, read some of my stuff, think about that a little bit and put it into action. I think you’ll find that these patients are much less intimidating, they’re much less frustrating. When you actually impact them in a positive way, it’s extremely rewarding and they’re very appreciative because they’ve been sort of left for dead metaphorically at least by the system and they’re extremely appreciative. They send in a lot of people to your practice because they know other people with the issue.
It can be really rewarding. I hope it’s helpful to everybody.
K. Fitzgerald: Yeah, absolutely. Thank you so much.
Dr. D. Brady: Thank you Kara.
K. Fitzgerald: All right, everybody, until next time.