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early to middle adulthood. Fibromyalgia is characterized by widespread pain and tenderness in muscles, ligaments and tendons. Sleep disturbances, fatigue, depression, Case Study:
headaches and irritable bowel syndrome are the most common health problems that can be associated with this A Comprehensive
disorder. Chronic widespread pain of at least 3 months duration and 11 of 18 predetermined points on the body must be tender in order to establish a diagnosis of fibro- Approach to Pseudo
myalgia. There are many theories about the causes of fibromyalgia which include a traumatic injury, infection, Fibromyalgia
altered muscle metabolism, sleep disturbances and sympathetic nervous system dysregulation. Pseudo by: Nikolas R. Hedberg, DC, DABCI fibromyalgia has recently been described in the literature and can be broken down into three categories: Abstract:
1. Organic Diseases: Lyme disease, hypothyroidism, Introduction: This case report describes a woman
rheumatoid arthritis, cancer, and anemia. diagnosed with pseudo fibromyalgia of 35 years duration 2. Functional Disorders: improper diet, intestinal achieving complete symptom resolution after DMSA dysbiosis, impaired liver detoxification, and oral chelation, a comprehensive detoxification program, antioxidant supplementation, dietary modification and 3. Musculoskeletal Disorders: multiple trigger points, disk/facet lesions, postural distortion, muscle Case Report/Methods: This patient had elevated levels
of mercury and lead upon DMSA urine challenge Traditional medicine uses a pharmaceutical approach to testing. In addition, she had 6 mercury-containing dental fibromyalgia utilizing analgesics, antidepressants, amalgams removed at the beginning of treatment. The muscle relaxers and a relatively new FDA-approved anti patient was placed on a three weeks on and one week off -seizure medication called Lyrica (pregabalin). DMSA oral chelation protocol for six months. Support- Cognitive behavioral therapy, mild exercise and ive nutritional and detoxification supplementation were relaxation techniques are becoming more accepted. used in addition to the DMSA. A diet that supports the Many so called alternative therapies have not been detoxification systems of the body was also utilized. thoroughly investigated in the literature. Toxic metals have been linked to fibromyalgia including allergic and Results: After four months of treatment all symptoms
autoimmune responses to metals such as mercury and that the patient had been experiencing for 35 years nickel. Integrative physicians report success when toxic completely resolved. Symptoms included chronic wide- metals are removed from the system as well as spread muscle pain, insomnia, fatigue, depression, digest supportive antioxidant therapy, detoxification, dental -ive problems, impaired mental function and blurry amalgam removal and dietary modification. This case study illustrates the novel approach of these methods in Discussion: This case illustrates a novel, safe and
effective treatment option for patients with pseudo Case Report:
fibromyalgia. Toxic metal allergy, immune dysfunction, A 65 year old female presented with a diagnosis of impaired liver detoxification, hypothyroidism, and oxi- fibromyalgia of 35 years duration. She was initially diag dative stress/antioxidant insufficiency have been shown -nosed by a rheumatologist as having fibromyalgia of to contribute to pseudo fibromyalgia. The multi-faceted unknown origin upon referral from her primary care treatment plan addressed these possible causes yielding a MD. Over the last 35 years she has not received any forms of treatment for her condition and was told that there was nothing that could be done by the physicians Introduction:
she has regularly seen. There was no traumatic pre- Fibromyalgia or Fibromyalgia Syndrome (FMS) is a cipitating event reported such as death of a loved one, disorder that affects approximately 2% of the US divorce, infection or physical trauma. The patient does population with females having a higher rate than males not recall anything that could have triggered her at a ratio of 9:1. Fibromyalgia tends to develop during condition indicating a more accurate diagnosis of pseudo THE ORIGINAL INTERNIST MARCH 2009 fibromyalgia. Palpation revealed the minimum criteria of toxic metal binding agent known as a chelator and at least 11/18 tender points required for the diagnosis of observe what metals are drawn out of the tissues which fibromyalgia, but this criteria is fatally flawed as many end up in the urine. Doctor’s Data was the laboratory conditions can result in multiple tender trigger points. In addition to chronic widespread muscle pain she reported digestive problems, impaired mental function, fatigue, Initial results:
blurred vision, and mild episodes of depression and Initial test results revealed elevated levels of lead and sleep problems due to her inability to find a sustained mercury. After reviewing the test results with the patient pain-free position in bed. Since the initial diagnosis was she decided to have all six of her dental amalgams made, she reports flare-ups of her condition approx- removed. She began a comprehensive heavy metal imately 3-4 times per year that would last 1-2 months. detoxification program approximately 1 week before During these flare-ups her pain would significantly dental amalgam removal. Her program consisted of the increase to an 8/10 and her concomitant symptoms would also increase. The patient cannot pin-point anything that may trigger these events. Six mercury- 1. DMSA 500mg in divided doses taken on Monday, containing dental amalgams were implanted during her teenage years but none since then. The patient also 2. Complete mineral complex taken every day of the reported a strong metallic taste in the mouth. program. (DMSA also removes essential minerals so these were replenished during the cycle) After a review of medical records, case history, physical 3. N-acetyl cysteine 1,000 mg three times a day. (NAC exam and comprehensive blood chemistry it was decided to test for heavy metal toxicity. A DMSA provoked increases glutathione production which is required urine challenge test was performed to establish a base- line. DMSA, or meso 2,3 dimercaptosuccinic acid has 4. Liver and gall bladder support complex taken with been used in traditional and alternative medicine to bind each meal during all parts of the cycle. (high levels and remove toxic metals. Oral DMSA at 20mg/kg of of mercury are excreted through the liver/gall bodyweight was given upon arising on an empty stomach and urine was collected for six hours. The 5. Vitamin C 1,000mg three times a day during all purpose of the challenge test is to give a patient a known 6. Comprehensive antioxidant complex three times a important antioxidant. Eggs contain choline which is day during all parts of the cycle. This product contained vitamin E, C, lipoic acid, green tea (50% The patient was instructed to divide her body weight in EGCG), grape seed extract, leucine, turmeric (95% half and drink that number in ounces of water every day curcuminoids), molybdenum, manganese, zinc, to help in detoxification. In addition, one tablespoon of biotin and selenium (Antioxidants are given to ground flax seed was consumed in the morning and at prevent cellular DNA damage due to increased night for extra fiber to ensure frequent bowel movements reactive oxygen species from toxic metals and aid in At the end of the first 3-week cycle the patient reported a reduction in all original symptoms and rated her pain a This plan was followed for three weeks and then DMSA 7/10. At the end of the second 3-week cycle the patient was discontinued for one week. Then another three rated her pain a 4/10 and had improvement in all weeks and she was retested to monitor progress. The symptoms. The second retest occurred at this point after author finds it useful to retest after every two, 3-week Lead and mercury levels had reduced at this point. The A heavy metal detoxification diet was also given to the patient continued the treatment plan for another two 3- patient. This diet was designed to support the body’s week cycles at which point all of her symptoms had detoxification systems with foods that contained high completely resolved including the muscle pain she was levels of taurine, sulfur-containing amino acids such as experiencing. A second retest was performed at this methionine and foods that increase bile flow. The following methionine rich foods were emphasized in the Mercury levels had reduced to the normal range while lead levels actually increased from the second test. The Beans, eggs, onions, garlic, cottage cheese, lentils, author finds fluctuations in metals such as lead when To increase bile flow, dandelion greens and turmeric The only side effects that were reported were mild gas were emphasized. The body converts methionine into and mild stomach discomfort which cleared after the cysteine which makes glutathione. Lipoic acid can also initial week of treatment. The muscle pain that she had be made from methionine and cysteine which is an been experiencing for 35 years was completely gone. THE ORIGINAL INTERNIST MARCH 2009 She was able to sleep through an entire night without patient does not fit for “classic” fibromyalgia, but does pain which helped to eliminate the chronic fatigue she fit for “pseudo” classification. They suggest that vitamin had been experiencing. The “fibro fog” cleared and her and mineral deficiencies, toxicity such as; heavy metal blurry vision improved significantly. The depressive overload, hypothyroidism and impaired liver detox- episodes that had occurred along with the flare-ups ification can be a cause of fibromyalgia-like symptoms. resolved as well. The metallic taste that was in her There are a few possibilities as to why this patient mouth was completely gone and she reports being more responded so well to this approach. Mercury inhibits the mobile. Her occasional digestive inconsistencies re- 5’-deiodinase enzyme which converts thyroxine into the solved. The patient also lost 15 pounds during the more active form of thyroid hormone triiodothyronine. program and states, “this is the best I’ve felt in ten Mercury also has a direct effect on thyroid hormone years.” For the first time since being in pain she has been production by interfering with thyroid peroxidase. The able to garden, which has always been one of her detoxification program used not only targeted toxic passions. It should be noted that this patient will metal removal but also liver detoxification support, continue treatment until lead levels are reduced to an vitamins, minerals, and antioxidants through supple- mentation and diet. Increased tissue toxicity can cause oxidative stress in mitochondria leading to a decrease in Discussion:
adenosine triphosphate production. A build-up of anaerobic metabolites such as lactic acid can cause Toxic metals have been linked to fibromyalgia including muscle pain similar to that of what is classically allergic and autoimmune responses to metals such as experienced in fibromyalgia. The patient was given more mercury and nickel. The combination of mercury- than adequate antioxidants during the entire treatment containing dental amalgam removal, detoxification, program reducing this possibility. This mechanism can antioxidant support, dietary modification and toxic metal also explain the fatigue and “fibro fog” that some elimination, have been reported by clinicians to improve experience. If the patient’s immune system was and sometimes completely eliminate fibromyalgia producing antibodies to mercury then removal of the related symptoms such as reported in this case. Brady et hapten (mercury) may have resulted in a decreased al., have made the case for a broader categorization of immune response reducing inflammatory cytokines. patients diagnosed with fibromyalgia. They outline the causes of “classic” fibromyalgia versus “pseudo” fibro- The limitations of this study include the fact that the myalgia. According to the criteria they present, this mercury-containing amalgams were removed approx- imately the same time the treatment plan was started. 8) Hench PK. Evaluation and differential diagnosis of The patient could have very well achieved the same fibromyalgia: approach to diagnosis and management. resolution of symptoms without the treatment plan. It could also be said that the amalgams were not the cause 9) Lowe JC. The metabolic treatment of fibromyalgia. of symptoms and that the toxic metal chelation and 10) Bland J. Bralley A. Nutritional up-regulation of hepatic increased intake of vitamins, minerals, antioxidants, detoxification enzymes. J Appl Nutr 1992;44:2-15. liver detoxification support and dietary changes were the 11) Rowe AH. Allergic fatigue and toxemia. Ann Allergy 12) Pressman AH. Metabolic toxicity and neuromuscular Conclusion:
pain, joint disorders, and fibromyalgia. J Am Chiro Assoc The original diagnosis of fibromyalgia made 35 years 13) Sprott H, Salemi S. Increased DNA fragmentation and ago may have been too general in nature and a more ultrastructural changes in fibromyalgic muscle fibers. Ann thorough evaluation of the cause may have yielded more answers for the patient. Despite the fact that this patient 14) Abraham GE, Flechas JD. Management of fibromyalgia: met all the criteria for a diagnosis of fibromyalgia, she rationale for the use of magnesium and malic acid. J Nutr did not have a classical cause of fibromyalgia such as; an extremely stressful event, trauma or infection. Her 15) Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of symptoms came on gradually with no known cause. fibromyalgia syndrome: analysis of referrals. Rheum- This patient had seen multiple physicians over the 35 16) Sterzl I, Prochazkova J. Mercury and nickel allergy: risk year period and the original diagnosis was never factors in fatigue and autoimmunity. Neuro Endrocrinol questioned, nor was there further evaluation. Toxic metal oral chelation with DMSA, dental amalgam removal, 17) Brady DM, Schneider MJ. Fibromyalgia syndrome: a antioxidant and detoxification support and dietary new paradigm for differential diagnosis and treatment. J modification may be a safe and effective way to remove Manipulative Physiol Ther. 2001 Oct;24(8):529-41. metals from the body that could potentially be causing fibromyalgia-like symptoms. Physicians may consider 18) Khaleeli A, Griffith DG, Edwards RH. The clinical toxic metal screening, dental amalgam removal and presentation of hypothyroid myopathy and its relationship treatment as outlined in this case for patients who to abnormalities in structure and function of skeletal present with fibromyalgia-like symptoms. 19) Bowman C Jeffcoat WJ, Pattrick M, Doherty M, Bilateral Dr. Nikolas R. Hedberg is a Board Certified Chiropractic adhesive capsulitis, oligoarthritis, and proximal myopathy Internist practicing in Asheville, NC. He can be reached as presentation of hypothyroidism. Br J Rheumatol at 828-687-2344 or 20) Golding DN. Hypothyroidism presenting with muscul- References:
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December 2008 (Vol. 1, Issue 3, pages 45-46) ROLE OF THE ENDOCANNABINOID SYSTEM IN ATHEROSCLEROSIS By François Mach, MD, Fabrizio Montecucco, MD, Sabine Steffens, PhD Division of Cardiology, Foundation for Medical Researches, University Hospital, Geneva, Switzerland Introduction Atherosclerosis is an inflammatory disease that involves vascular and immune cell types. En

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