Fibromyalgia

Angela Jones describes this painful condition while Tom Whitmarsh reports on the treatment of two of his patients

Fibromyalgia is nothing new. A cond­ition involving widespread pain in the muscles has been recognised for centuries and given various names, including “rheumatism” and later “mus­cular rheumatism”. It was not until the early 20th century that Gowers des­cribed “fibrositis”. The next step for­ward came in the 1970s when the term “fibromyalgia” was coined and recog­nition of the links between fibromyal­gia and other similar syndromes being described came during the 1980s.

However, its acceptance as a med­ical diagnosis did not come until much later, with the American College of Rheumatology publishing its criteria for diagnosis of fibromyalgia syndrome (FMS) in 1990, thus establishing the problem as an “official” illness.

Nevertheless, as a recent exchange on the web site of the Wall Street Journal will testify, there is still a good deal of controversy about fibromyalgia, more recently triggered by the licensing of an expensive medication also used in the treatment of epilepsy and other forms of chronic pain, specifically for use in fibromyalgia, by the American Food and Drug Administration.

Fibromyalgia is one of the medical conditions in which there is duplicated positive research evidence for homeo­pathy, using placebo-controlled trials, of good or very good quality.

Definition and symptoms of FMS
Fibromyalgia syndrome is a common rheumatological condition characterised by chronic widespread pain and ten­derness at specifically defined points. Painful stimuli are often felt very intensely(hyperalgesia) and non-painful stimuli, such as brushing, can also be felt as pain (allodynia). People with FMS often have other problems, including fatigue, depression, anxiety, sleep dis­turbance, headache, migraine, variable bowel habits and diffuse abdominal pain (irritable bowel syndrome) and urinary frequency. It is also said to be found more frequently in patients diagnosed with rheumatoid arthritis and systemic lupus erythematosus (SLE).

The American College of Rheuma­tology has defined the criteria most commonly used for diagnostic purposes: presence of widespread pain for at least three months, and all of the following (see diagram in PDF version of this article):

  • pain on the right and left sides of the body;
  • pain above and below the waist;
  • pain in the axial skeleton;
  • pain on palpation in at least 11 of 18 tender points.

What causes fibromyalgia?
The cause of FMS is not known. It is likely that different people diagnosed with FMS are actually suffering from the symptoms for different reasons and some of the suggestions include hyper-excitability of the central nervous system and alterations in the mechanisms for the perception of pain as well as inter­actions with the limbic system which governs sleep, and stress and immune regulating systems.

How common is fibromyalgia?
Estimates of how many people suffer from FMS vary. A US population study in 2006 based on health insurance data suggested one in 72 people was affected with a 62/38 split female to male. This is interesting as previous surveys suggested a much higher incidence in women but it could be that men suffer­ing from the disease are more likely to attract a diagnostic label and treatment within the US health system.

How is fibromyalgia treated?
To date there is no guidance available although an application has been made to the UK National Institute for Health and Clinical Excellence (NICE) for guide­lines to be developed. Evidence-based and expert opinion-based recommend­ations were published by a European multidisciplinary taskforce (EULAR) in 2007 and are summarised in the box overleaf.

Homeopathy and FMS
As we have seen, FMS is a condition which can present in many different ways. Every patient with FMS has their own story, their own constellation of symptoms, their own trigger factors, their own way of coping with the illness. In this kind of situation, the homeo­pathic approach comes into its own, allowing for the individualisation of a remedy or medicine to match the fea­tures displayed by the patient.

As with most homeopathic treat­ment, the medicine may be chosen on the basis of the symptoms of the illness, or on the characteristics of the patient as a whole (constitutional prescribing), or both. Dr Tom Whitmarsh demon­strates a range of approaches in the case studies described later. What is clear is that, as always with homeopathy, the medicine must be individualised to the patient and the case in order to be suc­cessful.

These are a few local remedies, which could be considered for people with FMS but be aware that they can only be expected to be helpful if the symptoms match those of the patient well.

Rhus tox: this is the rheumatism remedy par excellence and was the rem­edy studied by Dr Peter Fisher in the 1980s and shown to be effective in a double blind placebo-controlled trial of fibromyalgia. It is effective for pain and stiffness which is worse when having been still and gets better for getting moving, particularly bad after overdo­ing things or in cold damp weather, eased by warmth and moderate exercise. It is interesting to note how these match up with the conventional recommendations below!

Ruta grav: the remedy picture is sim­ilar to Rhus tox except that the stiffness is, if anything, more marked and less susceptible to improvement with gentle movement. There is often involvement of the tendons or the places where ten­dons meet bone (heels, elbows etc). There is often a bruised feeling. Pains are worse for cold damp weather but without the definite benefit from warmth which is seen in Rhus tox.

Rhododendron: the picture is very similar to Rhus tox except that the pains are very much worse for changes in the weather, especially if there is an impend­ing storm or thunderstorm.

Arnica: this medicine is best known for its action on injuries to reduce bruis­ing and swelling. However, it is useful whenever the body feels bruised and sore, especially if markedly worse after exertion. A characteristic feeling des­cribed is of “the bed feeling too hard”, in other words, soreness and bruised feeling is worse if the part is lain upon. Arnica can be a good medicine to start treatment of fibromyalgia with, if there is not a clear picture suggesting another medicine at the onset. Hopefully, after a period, a clearer picture will develop.

Causticum: again, soreness, weak­ness and stiffness, worse with exertion and cold, better for warm applications and being warm in bed. The unusual thing that might suggest Causticum is that the symptoms are worse in dry weather and better when it rains!

Bryonia: for Bryonia to work, the pain must be very much worse for the slightest movement (the opposite of Rhus tox). Heat will aggravate the pain and pressure on the relevant part alle­viates, possibly by preventing move­ment. In my experience, this is a more unusual presentation for fibromyalgia.

Kalmia latifolia:
this medicine is especially helpful for severe shooting pains in muscles, and there is often an accompanying numbness or cold sen­sation. Always make sure that there is no suggestion of nerve pressure or dam­age, if these symptoms are present.

Cimicifuga: this medicine is used where the pains, soreness and stiffness are mostly in the neck and upper back muscles. These may have been preceded by an injury and are generally worse for cold or drafts. Symptoms are often accompanied by headaches, especially on the top of the head or radiating up from the neck.

The European multidisciplinary taskforce evidence-based and expert opinion-based recommendations:

  • Full understanding of fibromyalgia requires comprehensive assessment of pain, function, and psychosocial context. Fibromyalgia should be recognised as a complex and heterogeneous condition where there is abnormal pain processing and other secondary features.
  • Optimal treatment requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored accord­ing to pain intensity, function, associated features such as depression, fatigue and sleep disturbance in discussion with the patient.
  • Heated pool treatment with or without exercise is effective in fibromyalgia.
  • Individually tailored exercise programmes including aerobic exercise and strength training can be beneficial to some patients with fibromyalgia.
  • Cognitive behavioural therapy may be of benefit to some patients with fibro­myalgia.
  • Other therapies such as relaxation, rehabilitation, physiotherapy and psycho­logical support may be used depending on the needs of the individual patient.
  • Tramadol is recommended for the management of pain in fibromyalgia. Simple analgesics such as paracetamol and other weak opioids can also be considered in the treatment of fibromyalgia. Corticosteroids and strong opioids are not recom­mended.
  • Antidepressants: amitriptyline, fluoxetine, duloxetine, milnacipran, moclobe­mide and pirlindole, reduce pain and often improve function therefore they should be considered for the treatment of fibromyalgia.
  • Tropisetron, pramipexole and pregabalin reduce pain and should be considered for the treatment of fibromyalgia.

Case studies
Tom Whitmarsh describes two cases of fibromyalgia
In my experience at Glasgow Homeo­pathic Hospital, it is unusual to find someone with symptoms of fibromyal­gia just on its own. Most people affected are struggling with multiple diagnoses and so many things feel wrong in addi­tion to the pure symptoms attributable to fibromyalgia.

I quite often find myself giving more than one medicine, often addressing the constitution with one remedy and the pain with another, perhaps in a lower potency.

Case one
Fay is 64. She has described herself as a “career woman”, working for and event­ually running various companies and always active and engaged fully with life. She first sought homeopathic help when she was 54. She had had pain in the chest fully investigated conven­tionally and little was found, though she had had lifelong heartburn. She had had a lot of anti-acid medications for this and was eventually found to have gallstones for which she had her gall­bladder removed.

She suffered from recurrent attacks of bronchitis and to crown it all, fell down some steps on the way to her gar­den and sustained a crushing of one of her spinal vertebrae at the age of 52. She was subsequently found to have general thinning of the bones (osteoporosis). Soon after the fracture of the spine and the discovery of osteoporosis, she began to suffer from widespread aches and pain in her muscles. She saw a rheuma­tologist, who did lots of tests (mostly negative) and confirmed a diagnosis of “secondary fibromyalgia”.

A highly communicative woman, Fay suffers a constant feeling of heat throughout the body and notices how easily she comes out in bruises at the slightest knock. She described her expe­rience of the pain – “it feels as if the body is on fire”, or the pain can be sharp and stabbing. It is particularly bad when she tries to use her arms. The example she gave was how uncomfortable it is to stand and chop vegetables. “It is a pain I cannot bear.” If sitting down and the pain gets bad, then she can find herself sliding down the chair, which gives a small measure of relief. She hates to be constricted with any tight clothing and very much prefers loose things to wear.

She had become miserable and depressed at her inability to cope with the pain brought on by the normal tasks of living – she had been so fit and active. She was helped with pain in her ankles, knees, lower back, shoulders and wrists initially by addressing the vertebral frac­ture with a high potency (200c) of Arnica and also Arnica cream to rub into the back. The remedy which has been most helpful for her generally has been Lachesis, in high potency, 200c three doses over 24 hours, and then LM1 five drops daily. This she says, “lifts the mood” and “helps a lot to let me cope”. The particular muscle pain all over the body was helped with regular doses of Rhus tox 6c three times a day.

Case two
Patricia is 45. She was referred for in­patient care by her rheumatologist, who had performed many tests and made diagnoses of depression and fibromyal­gia. It was noted in the referral that she was undergoing some marital dishar­mony. Her husband had affairs while she was unwell and suffering from panic attacks, as well as a very reduced libido. They went to Relate for counselling together, but she remained worried that it might happen again and she had lost her trust in her husband. She is quite fas­tidious about the state of her home and one of her big upsets is that because of the pain in the muscles, she is no longer able to be as tidy as she wants to be in her house.

She has two children who are well and a grandson whom she adores. She describes them all as being “very much part of my life” and she gives the air of being a welcoming mother to them all. Every detail of their lives concerns her.

She has pain in all her muscles from the neck down, which she describes as “like someone inside, twisting my mus­cles and joints”. There’s also an “excru­ciating nerve pain”, like a dentist hitting something with a drill, in the muscles most days. The pain is worse with any activity. It is exhausting and she suffers “horrible fatigue” by the end of every day. She has frequent dreams of her childhood family home and her parents.

She was scared to leave her husband, although he continued to have affairs and was unsupportive of her illness as she was scared of “splitting the family up”. She was admitted to Glasgow Homeopathic Hospital and given the remedy Calc carb 200c, three doses over 24 hours and the LM1 five drops daily. The next time we saw her, three months later, she had made definite plans to leave her husband and was feeling a lot calmer because of this decision. The pain was unchanged. The potency of the rem­edy was increased to LM2 and the pain has begun to come under control. She still plans to leave as well.

Calc carb is often given to people who invest a lot of their energy in home­making and making the home beautiful for their family. One can see what a des­perate betrayal the husband’s serial infi­delity is for such a person and why it might make them particularly unwell. So in this case, the constitutional rem­edy was all that has been required.

Dr Angela Jones is an NHS GP who trained in homeopathy in London and Bristol in the early 1990s. She worked in a large practice in South Wales for ten years and had a private homeo­pathic practice based in Cardiff. After returning to England in 1999, she ran a BHA-funded clinic in Didcot, Oxfordshire with Dr Nick Salzman. She continues to use homeopathy in her cur­rent NHS role, which is working mainly with people experi­encing homelessness.

Tom Whitmarsh MA MBBS FRCP FFHom is Consultant Physician at Glasgow Homeopathic Hospital.