Many patients suffer from chronic pain, fatigue, and inflammation due to disorders such as fibromyalgia (FbM), chronic fatigue syndrome (CFS or myalgic encephalomyelitis), or multiple chemical sensitivity (MCS or environmental sensitivity). Common symptoms to all three disorders include fatigue, pain, sleep disruption, and neurocognitive changes (Figure 1).¹ Fibromyalgia involves a constellation of symptoms, including persistent pain, non-pain-related symptoms, comorbid disorders such as autoimmunity, and psychological distress. The presence of widespread musculoskeletal pain and trigger points is considered specific to the diagnosis of fibromyalgia.²

Figure 1. Distinguishing characteristics and common symptoms of CFS, FbM, and MCS.

These patients receive little relief from their primary care providers, and up to 73% of patients meeting fibromyalgia diagnostic criteria may be misdiagnosed.³ Of note, studies reveal that, in the United States, a fibromyalgia diagnosis is often incorrectly assigned to white married women with higher rates of poly-symptoms (somatization) but lower pain and/or trigger point scores. Seeking relief, patients often turn to functional, naturopathic, or other forms of alternative medicine care in search of answers and support.⁴

Identifying Fibromyalgia

The use of available diagnostic tools such as the Polysymptomatic Distress Scale and the Fibromyalgia Survey Questionnaire may improve diagnosis; further discussion of these documents is beyond the scope of this article.^{5, 6} Since diagnostic criteria are still being refined, an awareness of the known risk factors for fibromyalgia may also be useful for clinicians.^2,3,7 Asian ancestry is protective; the risk of FbM is spread equally over all other ethnic populations. Expect a higher incidence of fibromyalgia if the patient has the following:

• Female gender

• US citizenship

• Social/economic disadvantage

• Western diet and lifestyle

• Lower education level

• Obesity

• Smoker

• Divorced or separated

• Midwest zip code

Comorbid conditions are common with fibromyalgia; however, the presence of a comorbid disorder does not contraindicate a diagnosis of fibromyalgia when it is appropriate.^2,8,9 Co-morbid conditions may include:

• Cardiovascular disease or hypertension

• Liver disease or hepatitis

• Kidney disorders

• Diabetes

• COPD/Emphysema

• Asthma

• Gastric ulcer

• Autoimmune disorders: RA 15% FbM; SLE 1.4% FbM

• Migraines

• Neuropsychiatric disorder

• Depression, phobia, bipolar, etc.

• Cancer

• Low back pain

• Gout or unspecified arthritis

Particularly strong co-associations may be seen with insomnia, cognitive decline, fatigue, anxiety, depression, or post-traumatic stress disorder because there is a strong association between trauma (physical or psychological) and the development of fibromyalgia (Figure 2).^4,10,11 There is also a growing association between fibromyalgia and type II diabetes.¹²

Figure 2. There is a strong association between trauma (physical or psychological) and the development of fibromyalgia.

Fibromyalgia and Inflammation

The known associations between fibromyalgia, autoimmunity, and Western lifestyle indicate that the assessment and management of inflammation may have profound effects in reducing the chronic symptoms of fibromyalgia and its co-morbid inflammatory disorders.^13-15 The chronic inflammation associated with FbM may originate in either immune system or mitochondrial dysregulation.¹⁶ Mitochondrial function plays a role in the body’s innate immune responses, and in the body’s recovery from stress or injury-altered mitochondrial function.^17,18 Mitochondrial dysfunction reduces aerobic mitochondrial respiration and dysregulates fatty acid oxidation. The loss of aerobic cellular respiration (OXPHOS) shrinks the thymus gland and reduces its ability to produce tolerant T-helper and T-regulatory immune cells that reduce inflammation (Figure 3).^{19, 20}

Figure 3. Aerobic mitochondrial respiration maintains tolerance and homeostasis. Inflammation, toxic exposure, and caloric or glucose excess may dysregulate mitochondrial respiration, causing pro-inflammatory changes in immune cells.

The chronic inflammation that dysregulates mitochondrial function and fatty acid oxidation pathways, whether from a comorbid disorder or environmental exposures, can be evaluated using a dried urine organic acids test (Figure 4).^21-24

Figure 4. Dried urine organic acids results indicate mitochondrial and primary biochemical pathway disruptions, many of which can be corrected with nutritional support and dietary or other lifestyle changes.

Organic Acids Testing for Fibromyalgia

Organic acids results provide information on glucose regulation, antioxidant status, mitochondrial function, use of dietary nutrients, liver detoxification, and digestive functions. This broad overview allows clinicians to personalize results to support specific biochemical or mitochondrial enzymes and functions with diet and nutrient cofactors.^25,26 Enzyme dysregulation occurs for a variety of reasons, including genetic and environmental epigenetic influences such as toxic exposures, nutritional deficiency, or overnutrition or lifestyle choices.^{21, 27-30}

Supporting enzymes and pathways with the appropriate personalized cofactors, and removing toxic exposures, food allergies and sensitivities may help to decrease inflammation and provide significant symptom relief for fibromyalgia sufferers and other inflamed (Figure 5).^14,16,25,26 The organic acids test can be repeated after a few months to monitor the effects of the nutritional protocol and lifestyle changes—improvements on the test usually reflect improvements in the patient.²² The organic acids test may also indicate the need for additional testing, for example stool tests, toxic metals, or toxic chemical screenings.

Figure 5. Dried urine organic acids results indicate the specific effects of the current diet and needed nutritional supports.

Case Study

The dried urine organic acids results and energy pathway seen in Figures 4 and 5 are from a 49-year-old, female, fibromyalgia patient. This patient had suffered from fatigue and pain for over 10 years without resolution. She improved under the care of a licensed naturopathic physician, who started the patient’s recovery with food sensitivity testing, cranial-sacral therapy, and basic nutritional supports (Figure 6).^19,25,31-34

Figure 6. Food allergy or sensitivity may be a hidden source of inflammation.

Even with the improvements, however, the patient reported a need for vigilance about her energy use and conservation. After five months of care with no additional improvement, the ND ordered a dried urine organic acids profile (see Figures 4 and 5) and a screening test for common environmental chemicals (Figure 7).^24,30,35,36

Figure 7. Environmental pollutants such as chemicals or metals can disrupt immune responses and mitochondrial function.

Based on the results of the organic acids profile, the patient received an individualized protocol to support her mitochondrial function and biochemistry.^27,26,34 The environmental pollutants screen identified several chemicals in the patient’s environment. Once the chemical exposures were stopped and a gentle detoxification protocol, supported by the nutrients indicated in the organic acids results, was added, the patient began to improve.^14,30,37 The patient was functioning well enough by 2022 to weather a significant personal loss of a family member and a Covid-19 infection with only minor setbacks to her energy and health. The patient currently reports no fibromyalgia flares and is walking 10-11,000 steps daily without exertional fatigue.

Conclusion

The treatment of fibromyalgia depends on the proper diagnosis of the condition, the recognition of risk factors and other contributing factors, an understanding that fibromyalgia is usually a comorbid disorder, and strategies to reduce the underlying inflammation driving the symptoms.

A dried urine organic acids profile, screening for environmental pollutants such as chemicals or metals, and the elimination of allergy or sensitivity exposures can all be used in the assessment and treatment of fibromyalgia and other inflammatory disorders.

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