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Active Hydrogen Adrenal Extracts Alanine Alpha-Linolenic Acid Alpha-Lipoic Acid AMP Amylase Inhibitors Arginine Bee Pollen Beta Carotene Beta-glucan Betaine Beta-Sitosterol Biotin Borage Oil Boron Bovine Cartilage Bovine Colostrum Brewer's Yeast Bromelain Calcium Capsaicin Carnitine Carnosine Chitosan Chloride Chlorophyll Chondroitin Chromium CLA Cobalt Coenzyme Q10 Copper Creatine Cysteine DHA DHEA DMAE EGCG Evening Primrose Oil 5-HTP Fiber (Insoluble) Fiber (Soluble) Fish Oil Flavonoids Fluoride Folate Fumaric Acid GABA Gamma-Linolenic Acid Glucomannan Glucosamine Glutamic Acid Glutamine Glutathione Glycine Grape Seed Extract Histidine HMB Hydroxycitric Acid Indole Inosine Inositol Iodine Ipriflavone Iron Isoleucine Lactase Lecithin Leucine Lipase Lutein Lycopene Lysine Magnesium Malic Acid Manganese Mannose Melatonin Methionine Methoxyisoflavone Molybdenum MSM N-Acetyl Cysteine NADH Naringin Niacin Octacosanol Oligosaccharides Olive Leaf Extract Ornithine Oryzanol PABA Pancreatic Enzymes Pantothenic Acid Phenylalanine Phosphatidylserine Phosphorus Phytic Acid Policosanol Potassium Pregnenolone Probiotics Propolis Psyllium Pyridoxine Pyruvate Quercetin Resveratrol Retinol Riboflavin Ribose Royal Jelly SAMe Selenium Shark Cartilage Silicon Sodium Spirulina Spleen Extracts St. John's Wort Strontium Sulforaphane Sulfur Taurine Thiamine Tocopherol Tea Tree Oil Tyrosine Usnic Acid Valine Vanadium Vinpocetine Vitamin A Vitamin B1 Vitamin B2 Vitamin B3 Vitamin B5 Vitamin B6 Vitamin B9 Vitamin B12 Vitamin C Vitamin D Vitamin H Vitamin K Whey Protein Xylitol Zinc
Abalone Shell (shi jue ming)
Abutilon Seed (dong kui zi)
Acanthopanax Bark (wu jia pi)
Achyranthes (niu xi)
Aconite (fu zi)
Acorus (shi chang pu)
Adenophora Root (nan sha shen)
Agkistrodon (bai hua she)
Agrimony (xian he cao)
Ailanthus Bark (chun pi)
Akebia Fruit (ba yue zha)
Albizzia Bark (he huan pi)
Albizzia Flower (he huan hua)
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Alisma (ze xie)
Aloe (lu hui)
Alum (bai fan)
Amber (hu po)
Ampelopsis (bai lian)
Andrographis (chuan xin lian)
Anemarrhena (zhi mu)
Antelope's Horn (ling yang jiao)
Apricot Seed (xing ren)
Areca Peel (da fu pi)
Areca Seed (bing lang)
Arisaema (tian nan xing)
Ark Shell (wa leng zi)
Arnebia (zi cao or ying zi cao)
Arnica (arnica montana)
Artichoke Leaves (Cynara scolymus)
Ash bark (qin pi)
Ashwagandha (withania somniferum)
Aster (zi wan)
Astragalus (huang qi)
Aurantium (zhi ke [qiao])
Bamboo Juice (zhu li)
Bamboo Shavings (zhu ru)
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Benincasa Seed (dong gua xi/ren)
Benzoin (an xi xiang)
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Biota Leaf (ce bai ye)
Biota Seed (bai zi ren)
Bitter Melon (ku gua)
Bitter Orange Peel (ju hong)
Black Cohosh (sheng ma)
Black Plum (wu mei)
Black Sesame Seed (hei zhi ma)
Bletilla (bai ji)
Boneset (ze lan)
Borax (peng sha)
Borneol (bing pian)
Bottle Brush (mu zei)
Buddleia (mi meng hua)
Buffalo Horn (shui niu jiao)
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Bupleurum (chai hu)
Burdock (niu bang zi)
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Capillaris (yin chen hao)
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Carpesium (he shi)
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Chaenomeles Fruit(mu gua)
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Chinese Gall (wu bei zi)
Chinese Raspberry (fu pen zi)
Chrysanthemum (ju hua)
Cibotium (gou ji)
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Coix Seed (yi yi ren)
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Corn Silk (yu mi xu)
Cornus (shan zhu yu)
Corydalis (yan hu suo)
Costus (mu xiang)
Cranberry (vaccinium macrocarpon)
Cremastra (shan ci gu)
Croton Seed (ba dou)
Curculigo (xian mao)
Cuscuta (tu si zi)
Cuttlefish Bone (hai piao xiao)
Cymbopogon (xiang mao)
Cynanchum (bai qian)
Cynomorium (suo yang)
Cyperus (xiang fu)
Dalbergia (jiang xiang)
Damiana (turnera diffusa)
Dandelion (pu gong ying)
Deer Antler (lu rong)
Dendrobium (shi hu)
Devil's Claw (harpagophytum procumbens)
Dianthus (qu mai)
Dichroa Root (chang shan)
Dittany Bark (bai xian pi)
Dong Quai (tang kuei)
Dragon Bone (long gu)
Dragon's Blood (xue jie)
Drynaria (gu sui bu)
Dryopteris (guan zhong)
Earthworm (di long)
Eclipta (han lian cao)
Elder (sambucus nigra or sambucus canadensis)
Elsholtzia (xiang ru)
Ephedra (ma huang)
Epimedium (yin yang huo)
Erythrina Bark (hai tong pi)
Eucalyptus (eucalyptus globulus)
Eucommia Bark (du zhong)
Eupatorium (pei lan)
Euphorbia Root (gan sui or kan sui)
Euryale Seed (qian shi)
Evodia (wu zhu yu)
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Fenugreek (hu lu ba)
Fermented Soybeans (dan dou chi)
Flaxseed (ya ma zi)
Fo Ti (he shou wu)
Forsythia (lian qiao)
Frankincense (ru xiang)
Fritillaria (chuan bei mu)
Gadfly (meng chong)
Galanga (gao liang jiang)
Galena (mi tuo seng)
Gambir (gou teng)
Gardenia (zhi zi)
Garlic (da suan)
Gastrodia (tian ma)
Gecko (ge jie)
Gelatin (e jiao)
Genkwa (yuan hua)
Germinated Barley (mai ya)
Ginger (gan [sheng] jiang)
Ginkgo Biloba (yin xing yi)
Ginseng, American (xi yang shen)
Ginseng, Asian (dong yang shen)
Ginseng, Siberian (wu jia shen)
Glehnia (sha shen)
Glorybower (chou wu tong)
Goldenseal (bai mao liang)
Gotu Kola (luei gong gen)
Green Tea (lu cha)
Gymnema (gymnema sylvestre)
Gynostemma (jiao gu lan)
Gypsum (shi gao)
Halloysite (chi shi zhi)
Hawthorn (shan zha)
Hemp Seed (huo ma ren)
Homalomena (qian nian jian)
Honey (feng mi)
Honeysuckle Flower (jin yin hua)
Honeysuckle Stem (ren dong teng)
Houttuynia (yu xing cao)
Huperzia (qian ceng ta)
Hyacinth Bean (bai bian dou)
Hyssop (huo xiang)
Ilex (mao dong qing)
Imperata (bai mao gen)
Indigo (qing dai)
Inula (xuan fu hua)
Isatis Leaf (da qing ye)
Isatis Root (ban lan gen)
Java Brucea (ya dan zi)
Jujube (da zao)
Juncus (deng xin cao)
Kadsura Stem (hai feng teng)
Katsumadai Seed (cao dou kou)
Kelp (kun bu)
Knotweed (bian xu)
Knoxia root (hong da ji)
Kochia (di fu zi)
Lapis (meng shi)
Leech (shui zhi)
Leechee Nut (li zhi he)
Leonorus (yi mu cao)
Lepidium Seed (ting li zi)
Licorice (gan cao)
Ligusticum (chuan xiong)
Ligustrum (nč zhen zi)
Lily Bulb (bai he)
Limonite (yu liang shi)
Lindera (wu yao)
Litsea (bi cheng qie)
Lobelia (ban bian lian)
Longan (long yan hua [rou])
Lophatherum (dan zhu ye)
Loquat Leaf (pi pa ye)
Lotus Leaf (he ye)
Lotus Node (ou jie)
Lotus Seed (lian zi)
Lotus Stamen (lian xu)
Luffa (si gua luo)
Lycium Bark (di gu pi)
Lycium Fruit (gou qi zi)
Lygodium (hai jin sha)
Lysimachia (jin qian cao)
Magnetite (ci shi)
Magnolia Bark (hou po)
Magnolia Flower (xin yi hua)
Maitake (grifola frondosa)
Marigold (c. officinalis)
Massa Fermentata (shen qu)
Milk Thistle (silybum marianum)
Millettia (ji xue teng)
Mint (bo he)
Mirabilite (mang xiao)
Morinda Root (ba ji tian)
Mugwort Leaf (ai ye)
Mulberry Bark (sang bai pi)
Mulberry Leaf (sang ye)
Mulberry Twig (sang zhi)
Mullein (jia yan ye)
Musk (she xiang)
Myrrh (mo yao)
Notoginseng (san qi)
Notopterygium (qiang huo)
Nutmeg (rou dou kou)
Oldenlandia (bai hua she she cao)
Omphalia (lei wan)
Onion (yang cong)
Ophicalcite (hua rui shi)
Ophiopogon (mai dong)
Oroxylum Seed (mu hu die)
Oryza (gu ya)
Oyster Shell (mu li)
Passion Flower (passiflora incarnata)
Patrinia (bai jiang cao)
Pau D'Arco (tabebuia avellanedae)
Peach Seed (tao ren)
Pearl (zhen zhu [mu])
Perilla Leaf (su ye)
Perilla Seed (su zi)
Perilla Stem (su geng)
Persimmon (shi di)
Pharbitis Seed (qian niu zi)
Phaseolus (chi xiao dou)
Phellodendron (huang bai)
Phragmites (lu gen)
Picrorhiza (hu huang lian)
Pinellia (ban xia)
Pine Knots (song jie)
Pipe Fish (hai long)
Plantain Seed (che qian zi)
Platycodon (jie geng)
Polygala (yuan zhi)
Polygonatum (huang jing)
Polyporus (zhu ling)
Poppy Capsule (ying su qiao)
Poria (fu ling)
Prickly Ash Peel (hua jiao)
Prinsepia Seed (rui ren/zi)
Prunella (xia ku cao)
Prunus Seed (yu li ren)
Pseudostellaria (tai zi shen)
Psoralea (bu gu zhi)
Pueraria (ge gen)
Pulsatilla (bai tou weng)
Pumice (fu hai shi)
Pumpkin Seed (nan gua zi)
Purslane (ma chi xian)
Pyrite (zi ran tong)
Pyrrosia Leaf (shi wei)
Quisqualis (shi jun zi)
Radish (lai fu zi)
Realgar (xiong huang)
Red Atractylodes (cang zhu)
Red Clover (trifolium pratense)
Red Ochre (dai zhe shi)
Red Peony (chi shao)
Red Sage Root (dan shen)
Rehmannia (shu di huang)
Reishi (ling zhi)
Rhubarb (da huang)
Rice Paper Pith (tong cao)
Rose (mei gui hua)
Rosemary (mi die xiang)
Safflower (hong hua)
Saffron (fan hong hua)
Sandalwood (tan xiang)
Sanguisorba Root (di yu)
Sappan Wood (su mu)
Sargent Gloryvine (hong teng)
Saw Palmetto (ju zong lu)
Schefflera (qi ye lian)
Schisandra (wu wei zi)
Schizonepeta (jing jie)
Scirpus (san leng)
Scopolia (S. carniolica Jacq.)
Scorpion (quan xie)
Scrophularia (xuan shen)
Scutellaria (huang qin)
Sea Cucumber (hai shen)
Sea Horse (hai ma)
Seaweed (hai zao)
Selaginella (shi shang bai)
Senna (fan xie ye)
Shiitake (hua gu)
Siegesbeckia (xi xian cao)
Siler Root (fang feng)
Slippery Elm (ulmus fulva)
Smilax (tu fu ling)
Smithsonite (lu gan shi)
Sophora Flower (huai hua mi)
Sophora Root (ku shen)
Spirodela (fu ping)
Stellaria (yin chai hu)
Stemona (bai bu)
Stephania (fang ji [han])
Sweet Annie (qing hao)
Teasel Root (xu duan)
Tiger Bone (hu gu)
Torreya Seed (fei zi)
Tortoise Plastron (gui ban)
Tremella (bai mu er)
Trichosanthes Fruit (gua lou)
Trichosanthes Root (tian hua fen)
Trichosanthes Seed (gua lou ren)
Tsaoko Fruit (cao guo)
Turmeric (jiang huang)
Turtle Shell (bie jia)
Tussilago (kuan dong hua)
Urtica (xun ma)
Uva ursi (arctostaphylos uva-ursi)
Vaccaria Seed (wang bu lui xing)
Valerian (jie cao)
Veratrum (li lu)
Viola (zi hua di ding)
Vitex (man jing zi)
Walnut (hu tao ren)
Watermelon (xi gua)
White Atractylodes (bai zhu)
White Mustard Seed (bai jie ze)
White Peony (bai shao)
Wild Asparagus (tian men dong)
Windmill Palm (zong lu pi/tan)
Xanthium (cang er zi)
Zedoary (e zhu)
Fibromyalgia: Put the Pain in Its Place

3 essential considerations for chiropractors treating fibromyalgia patients.

By Courtney Craig, MS, DC

While some fibromyalgia patients respond favorably to regular chiropractic care, others experience minimal relief.1 Unfortunately, many of these patients must rely on pharmacological management to relieve their constant pain. The most common medications prescribed for fibromyalgia are anti-epileptic drugs like Lyrica, serotonin-norepinephrine reuptake inhibitors like Cymbalta, and newcomer Savella. All of these medications have high risk of side effects and cannot be stopped abruptly without a proper weaning schedule. Cymbalta withdrawal symptoms may be so severe in certain patients that the FDA issued notice, citing withdrawal as its own diagnosis: Cymbalta discontinuation syndrome.2

A Drug Effectiveness Review Project (DERP) meta-analysis indicated low-strength evidence of these drugs' effectiveness for managing overall fibromyalgia symptoms.3 Furthermore, the National Pain Foundation's large-scale 2014 survey of 1,339 fibromyalgia patients revealed that more than 60 percent of patients reported no improvements at all with these FDA-approved medications.4

Even more surprising, results from this survey showed 43 percent of fibromyalgia sufferers felt their physician was not knowledgeable about the disorder, and over a third felt their physician did not take their fibromyalgia seriously.

The Chiropractic Opportunity

Chiropractors are poised with the correct tools to effectively manage fibromyalgia patients. Do we take these patients' condition seriously? Knowledge and understanding of this common condition are essential for better results for these patients.

However, manipulation and myofascial strategies alone may be inadequate. To get the results these patients deserve, we must evaluate the literature and use all diagnostic and therapeutic tools at our disposal. Most important of all is instilling hope in the patient that their illness is in fact treatable.

It is all too common that patients receive a diagnosis of fibromyalgia without a thorough assessment. Some patients wait as long as five years to be diagnosed with fibromyalgia by exclusion. Yet, many times fibromyalgia symptoms can imitate other treatable conditions such as nutrient deficiency, celiac disease, non-celiac gluten sensitivity, or dysbiosis. These imitators are less frequently measured in allopathic medicine. Before reaching for manual methods to treat these patients, the chiropractor must first perform a careful reassessment and rule out these other potential, treatable conditions.

Screen for Nutrient Deficiency: Low Levels of Vitamin B12

Vitamin B12 deficiency frequently masquerades as fibromyalgia. The neuropathic-type pain experienced by these patients may be due to B12 deficiency. This deficiency is common in vegetarians, those with poor digestion or those with inadequate stomach acid due to chronic proton-pump inhibitor (PPI) use.

Vitamin B12 deficiency is frequently overlooked by many general practitioners and rheumatologists. This is partly due to the fact that serum B12 level is a notoriously unreliable marker. Urinary or serum methylmalonic acid (MMA) is a far better indirect assessment of functional B12 status and should be used to rule out deficiency.5

Screen for Celiac and Non-Celiac Gluten Sensitivity

It is now widely accepted that sensitivity to gluten is a spectrum disorder, far more prevalent than previously believed. Studies suggest that gluten sensitivity is common in fibromyalgia patients, yet many go undiagnosed;6 and that only half of gluten-sensitive patients have the HLA-DQ2 or HLA-DQ8 genotype, further complicating proper diagnosis.7

Part of the reason for this is that traditional gluten allergy testing looks for sensitivity to the peptide gliadin exclusively. Few clinicians are aware that there are at least 50 toxic epitopes in gluten, each capable of exerting cytotoxic, immunomodulating, and tight-junction activities.8 Better testing is now available that can provide an accurate diagnosis before villus damage occurs. However, the best and most affordable diagnostic tool is a gluten elimination diet for 30 days or more. A recent 2014 study suggested that gluten removal may not only improve symptoms, but also could result in complete fibromyalgia remission.7

Screen for Small Intestine Bowel Overgrowth (SIBO)

Some have suggested that the underlying cause of fibromyalgia is small intestine bowel overgrowth (SIBO). The presence of SIBO in fibromyalgia is far more prevalent than that seen in irritable bowel patients.9 With unwanted bacterial species in the small intestine, systemic inflammation is promoted, which disrupts tight-junction integrity. The "leakiness" of the mucosal lining allows for food antigens and lipopolysaccharide (LPS) from gram-negative bacteria to translocate into circulation.

From here, the immune system is triggered, releasing pro-inflammatory cytokines that can worsen the ongoing feeling of malaise. Additionally, LPS may cross the blood-brain barrier and lead to the "fibro fog" and memory problems common in these patients.10

The gold standard test for diagnosing SIBO is the lactulose-mannose challenge. Patients drink a sugar solution and breath measures for hydrogen and methane are taken over the course of several hours. Proper management of SIBO requires dietary changes as well as supportive supplements. Patients should eliminate sugar and refined carbohydrates from the diet to inhibit continued growth of the small-intestine bacteria. Additionally, herbal anti-microbials can be used such as oregano, golden seal, berberine, or wormwood.

To repair the inflamed intestinal mucosa and improve tight-junction integrity, nutraceutical support may include glutamine, zinc carnosine, deglycyrrhizinated licorice, and N-acetly L-cysteine. Repopulating the gut with beneficial species through ingestion of fermented foods and probiotic species will also be beneficial to prevent relapse due to overgrowth.

Provide Sleep Support

Unrefreshing sleep is a hallmark characteristic of fibromyalgia. In fact, the widespread pain experienced may be due to the fact that these patients do not enter deep delta wave sleep, during which growth hormone is released to promote tissue healing.11

Advising the patient on sleep hygiene and offering supportive supplements may improve energy levels and reduce pain. Studies suggest melatonin, glycine, theanine and magnesium may aid in sleep onset and deeper sleep.12 Additionally, traditional herbs such as hops, chamomile, passion flower and valerian are effective. These herbs are frequently part of supplement formulas, providing a synergistic effect.

A thorough, integrative approach to treatment will ensure the best results for fibromyalgia patients. Thus far, medication management has been grossly inadequate at providing relief. Many of these patients are improperly diagnosed, told there is no cure, or have spent years and countless dollars to get a diagnosis. Once diagnosed, they are told to cope with symptoms and learn to live with their condition. This unfortunate scenario promotes patient passivity and depression.

Because fibromyalgia patients flock to chiropractors for symptomatic relief, it is our duty to provide complete care, often beyond simple manual therapies, in order to empower the patient to achieve true health.


References

  1. Schneider M, Vernon H, Ko G, Lawson G, Perera J. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther, 2009;32(1):25-40.
  2. Cymbalta (Duloxetine): Discontinuation Syndrome Issues of Scope, Severity, Duration & Management. Food and Drug Administration, June 9, 2009.
  3. Drug Effectiveness Review Project, April 2011. By Beth Smith, DO, Kim Peterson, MS, Rochelle Fu, PhD, Marian McDonagh, PharmD, and Sujata Thakurta, MPA:HA. Portland (OR): Oregon Health & Science University.
  4. FDAReg Watch. "Marijuana Rated Significantly More Effective in Treating Fibromyalgia Symptoms than FDA-Approved Drugs, Global Survey Finds." Press release, April 21, 2014.
  5. Brown DL, Oh RC. Vitamin B12 deficiency. Am Fam Physician, 2003;67(5):979-986.
  6. Rodrigo L, Blanco I, Bobes J, de Serres FJ. Remarkable prevalence of coeliac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study. Arthritis Res Ther, 2013;15(6):R201.
  7. Isasi C, et al. Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int, 2014 (e-pub ahead of print).
  8. Fasano A. Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity, and cancer. Physiol Rev, 2011;91(1):151-75.
  9. Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing. Ann Rheum Dis, 2004;63(4):450-2.
  10. Vasquez A. Fibromyalgia in a Nutshell: A Safe and Effective Functional Medicine Strategy. Portland, OR; Integrative and Biological Research and Consulting, LLC; 2012.
  11. Bennett RM. Adult growth hormone deficiency in patients with fibromyalgia. Curr Rheumatol Rep, 2002;(4):306-12.
  12. Bannai M, Kawai N, Ono K, Nakahara K, Murakami N. The effects of glycine on subjective daytime performance in partially sleep-restricted healthy volunteers. Front Neurol, 2012;3:61.

Dr. Courtney Craig is a DC graduate of Palmer College of Chiropractic Florida with a Master of Science in Human Nutrition from the University of Bridgeport. She is a health and nutrition consultant for chronic fatigue syndrome (CFS) and fibromyalgia, and offers patient education through blogs, webinars, and podcasting at www.drcourtneycraig.com. Dr. Craig has nearly two decades of experience as a CFS patient and, now recovered, is dedicated to advancing treatment and understanding of these conditions.

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