The Ayurvedic Approach to Fibromyalgia

Fibromyalgia (FM) is a chronic widespread pain disorder often seen in primary care practices. Advances in the understanding of FM pathophysiology and clinical presentation have improved the recognition and diagnosis of FM in clinical practice. Fibromyalgia is a clinical diagnosis based on signs and symptoms and is appropriate for treatment through Ayurvedic medicine. The hallmark symptoms of FM are chronic widespread pain, fatigue, and sleep disturbances. Awareness of common mimics of FM and co-morbid disorders will increase confidence in establishing a diagnosis of FM.

Current Western Medical View
Though not conclusive, FM patients have been found to have lower levels of a brain neurotransmitter called serotonin, which leads to lowered pain thresholds and increased sensitivity to pain. Serotonin also promotes a calm, stable mental state. The lowered pain thresholds in fibromyalgia patients may be caused also by the reduced effectiveness of the body’s natural endorphins and the increased levels of a neurotransmitter called substance P which amplifies pain signals as well elevated levels nerve growth factor in the spinal fluid of fibromyalgia patients. The latter is a small protein important for the growth, maintenance, and survival of certain nerve cells.

Fibromyalgia (FM) is estimated to affect more than 5 million Americans (2%-5% of the adult population). It is second only to osteoarthritis as the most common disorder seen in rheumatology practices. In recent years, increasingly more patients with FM are presenting to primary care clinicians for initial diagnosis and ongoing care. Fibromyalgia is a persistent and potentially debilitating disorder that can have a devastating effect on quality of life, impairing the patient’s ability to work and participate in everyday activities, as well as affecting relationships with family, friends, and employers. It imposes heavy economic burdens on society as well as on the patient.

Recent research suggests that the chronic widespread pain that is the hallmark symptom of FM is neurogenic in origin. Fibromyalgia is associated with a central amplification of pain perception characterized by allodynia (a heightened sensitivity to stimuli that are not normally painful) and hyperalgesia (an increased response to painful stimuli). Neuroimaging studies have also shown that FM is associated with abnormal processing of painful stimuli in the central nervous system.

Ayurvedic View
Fibromyalgia can be classified as mamsa dhatugat dushti (diseases affecting muscles and tendons) and mamsavrut Vāta (diseases of excess Vāta dosha in muscles and tendons). Additionally, it involves dysfunction in vāta vaha srota, mamsa vaha srota and mamsa dhatvagni. It falls into a subtype of disease known in Ayurveda as vātavyādhi (diseases caused primarily by vitiated Vāta dosha), but always has Paitaja and Kaphaja involvement and variations. Vātavyādhi is a disease of chronic and unpredictable (anavasthita) nature, difficult to cure, involving primarily the musculoskeletal system and the nervous system, but in time affecting one or more additional tissues. It is described in ancient texts as manifesting with a variety of possible and changing symptoms and signs including pain, stiffness, contracture, fatigue, gradual loss of movement, and mental disturbance. This description is remarkably similar to our modern description of fibromyalgia. Though primarily an affliction of Vāta dosha affecting muscle tissue, FM is undoubtedly a tridoshic disease.

The influence of Vāta, Pitta, and Kapha doshas on mamsa dhatu is often misunderstood. All structures which are composed of māmsa dhatu exclusively (e.g. biceps, heart) or in association with other dhatus (e.g. stomach, small intestines) will invariably manifest some form of gati (movement). Any such movements are initiated by Vāta in the form of nerve impulses acting on māmsa. Life as a dynamic phenomenon is possible to a great extent because of the capacity of mamsa dhatu to move. The external musculature as well as the visceral musculature (sphincters, arteries, gastrointestinal structures) all depend on the vitality of mamasa dhatu. Mamsa dhatus is one of five human tissues which are composed primarily of Kapha dosha. The term sleshma is synonymous with Kapha. Sleshma is etymologically derived from the Sanskrit root slish which means to keep together, embrace or cohere. Thus, it is understood that the intercellular cementing material which binds all muscle cells (in fact, all tissue cells) together is sleshaka kapha. Beyond its binding action, sleshaka kapha provides sthiratva (stability) and bala (strength) to muscle tissue.

Pitta dosha exerts its action on mamsa dosha through the misconstrued subdosha known as sadhaka pitta. Caraka tells us the site of sadhaka pitta to be “hridaya”—inadequately translated into English as the “heart.” In reality sadhaka is most accurately located in the part of the mind and body which conducts and regulates highly complex mental and physical activities. It is present at every neuromuscular junction where it precisely regulates the nervous impulses into the muscles. Fibromyalgia is caused due to an initial aggravation of Vāta leading to neurological signs and symptoms. Kapha and Pitta are vitiated to varying extents in different individuals, and thus fibromyalgia is best understood as a tridoshic disease.

As in a related disorder known as amavata (rheumatoid arthritis), the other main causative factors are ama and low agni. Ama is the result of defective digestive and metabolic mechanisms. Its formation is initiated by the consumption of diets prepared with some ingredients of opposite qualities (viruddha ahara) consumed in the presence of mandagni (low agni). Though, according to Ayurveda, ama and Vata dosha are the main pathogenic factors, Kapha and Pitta are also invariably involved in its pathogenesis.

Fibromyalgia is ādhyātmika (due to intrinsic imbalance). Primarily the pathogenesis (samprapti) originates in the gastrointestinal tract (anna vaha srota) then branches out through the madhyama rogamarga, the middle channels of pathogenic process of disease, with special inclination for shleshma sthana especially muscle tissues (mamsa dhatu) and their corresponding channels (srotasmi). Rasa, Asthi and Majja Dhatus are also often involved. Dushyas in sandhi (joints) and snayu (tendons and ligaments) also occur. Intolerability of even light touch (hyperalgia) in muscles (sparshasahyata) are a unique feature of the disease. The disease has a chronic course and malaise, anorexia, heaviness of the body, nausea, intermittent fever are responsible for gradually disabling patients.

Underdiagnosis
Despite improved understanding of its pathologic processes, FM remains undiagnosed in as many as 70% of people with the condition. Diagnosis time averages 5 years, resulting in delayed treatment and potentially suboptimal medical care. Women currently account for 80% to 90% of cases diagnosed. One fact that is commonly ignored is that most women are more sensitive to painful stimuli than men and therefore have a greater response than men to the diagnostic tender point examination that is included in the conventional medical criteria (tenderness on digital palpation at pre-designated sites). As a result, men with chronic widespread pain rarely meet ACR criteria for FM, despite having a similar underlying pathologic process.

Diagnosing Fibromyalgia
The diagnostic evaluation of FM can take time, but this should not be a barrier in primary care practices. If a diagnosis of FM is suspected, Ayurvedic treatment can begin while the evaluation for possible other coexisting disorders continues. Subsequent visits during initial diagnosis and management actually reassure the patient with FM that they are receiving appropriate care and validation, which can be very therapeutic.
Fibromyalgia is a clinical diagnosis based on the disorder’s unique clinical characteristics and not solely a diagnosis of exclusion. Like other pain states (e.g., migraine), FM is commonly diagnosed on the basis of characteristic symptoms.

A focused (a) patient history, (b) physical examination, and (c) ruling out co-morbid disorders are the cornerstones of FM recognition. No laboratory or radiologic testing is required to diagnose FM however can be useful to evaluate other potential co-morbid diagnoses. These tests include measurement of erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) levels, a complete blood cell count, a comprehensive metabolic panel, thyroid function tests, ferritin, iron saturation, and vitamins B12 and D. Testing for rheumatoid factor (RF) or antinuclear antibodies (ds-DNA) is recommended if the patient has signs or symptoms suggesting an autoimmune disorder.
It is important to identify FM and initiate treatment as early as possible, even if further evaluation is needed to identify and confirm other possible co-morbid conditions (i.e. hypothyroidism, Epstein-Barr viral infection, inflammatory arthritis) that may also require management.

a) Patient History
As stated in the first paragraph of this article, the core triad of FM symptoms include:

(1) Chronic widespread pain (in the right and left side of the body, above and below the waist, and in the axial skeleton) of long duration (2-3 months) as the primary, hallmark symptom
(2) Fatigue
(3) Sleep disturbance, including non-restorative sleep (feeling unrefreshed after a night’s sleep)

These 3 symptoms occur in most patients with FM. Thus in the real world, any patient complaining of chronic widespread pain for years, especially in the presence of fatigue and a sleep disturbance, should raise suspicion for FM. For many patients, the fatigue component of FM is the most troublesome symptom and the one that most commonly leads them to seek medical attention.

Other key associated symptoms include:
 tenderness
 stiffness
 mood disturbances (e.g., depression and/or anxiety)
 cognitive difficulties (e.g., trouble concentrating, forgetfulness, and disorganized thinking)

Fibromyalgia symptoms can wax and wane, varying in intensity from day to day and by physical location, all features which reflect its Vāta nature. Patients with FM frequently report impairment in multiple areas of function, especially physical function. Overall, patients with FM are a heterogeneous population. The impact of FM spans the continuum from patients who are mildly to moderately affect by FM symptoms to those who are more severely affected and have markedly impaired function and quality of life.

Fibromyalgia should be considered in all patients with multiple regions of chronic pain (at a single point in time or during the course of their lifetime), especially if they report multiple somatic symptoms. Generally, the index of suspicion for FM should increase the longer the chronic widespread pain and other symptoms have been present, the more variable the symptoms, and the more body systems that are involved.
The patient’s history may reveal risk factors for FM, such as familial predisposition. Relatives of people with FM are at a higher risk. In a recent family study, first-degree relatives of patients with FM were 8 times more likely to have FM than relatives of the control group of patients with rheumatoid arthritis (RA). Environmental factors, including physical trauma or injury, infections (e.g., Lyme disease and hepatitis C), and other stressors (e.g., work, family, life-changing events, and abuse history), pose additional risk.

b) Physical Examination
The physical examination of a patient with suspected FM should focus on identifying associated or
comorbid disorders as warranted by symptoms, signs, and the medical history because these may require separate management.
Joints should be examined for swelling, tenderness, range of motion, and crepitus, and patients should be evaluated for peripheral pain generators (e.g., RA, osteoarthritis, tendonitis, adhesive capsulitis) as well as focal and/or objective weakness. If the history is suggestive, signs of connective tissue disease should be assessed and a neurologic examination conducted.

It is important to note that the presence of a second disorder (even a painful one) does not necessarily exclude a diagnosis of FM, which can occur together with other painful conditions. In general, the physical examination findings are normal in FM except for diffuse tenderness, evaluated by counting tender points of several regions of the body. The physical examination (digital palpation of tender points) remains the key in the evaluation of patients to assess the tenderness (allodynia and hype-ralgesia) associated with FM and to aid in the differential diagnosis.

c) Co-morbid Disorders.
The presence of common comorbid disorders can also raise suspicion for FM, and it is important for the clinician to ask about chronic widespread pain when presented with these associated conditions. Examples of common co-morbid disorders include:
-depressive or anxiety disorders – spinal stenosis -irritable bowel syndrome – systemic lupus erythematosus -tension-type headache/migraine – osteoarthritis -interstitial cystitis – RA -chronic prostatitis – neuropathies -temporomandibular joint syndrome – sleep apnea -chronic pelvic pain

The high frequency with which FM and mood and anxiety disorders occur together is most likely explained by doshic abnormalities common to both mood and anxiety disorders and FM, rather than by FM causing the mood and anxiety disorders or the mood and anxiety disorders causing FM. Also, current medications should be identified and medication-related pain such as statin-induced muscle pain or opioid-induced hyperalgesia ruled out.

Tender Point Criteria
The American College of Rheumatology (ACR) criteria for FM (Figure 1) include a history of widespread pain lasting 3 months or longer. Widespread pain is defined as pain above and below the waist and on both sides of the body. In addition, axial skeletal pain (in the cervical spine, anterior chest, thoracic spine, or lower back) must be present. According to the ACR, a patient must have pain on digital palpation at 11 of 18 predesignated sites, commonly referred to as tender points, to be diagnosed as having FM. Approximately 4 kg of pressure must be applied to a site, and the patient must indicate that the site is painful. In practical terms, the pressure to assess tenderness with digital examination is the pressure needed to see your own fingernail bed blanch.

The ACR criteria have a sensitivity of 88.4% and a specificity of 81.1%. Many health care professionals find the manual tender point examination useful for confirming the presence of widespread tenderness and increasing confidence in the diagnosis. These criteria were originally designed to standardize patient classification in clinical trials rather than to diagnose FM in routine clinical practice. Nevertheless, the tender point examination has been used in hundreds of studies and is recognized by the ACR for the diagnosis of FM.
Digital palpation is performed with an approximate force of 4 kg. A tender point has to be painful at palpation, not just tender. The diagnosis of fibromyalgia requires pain at least 11 of 18 points:

Pain in 11 of 18 standardized sites, commonly referred to as tender points, on digital palpation:

Occiput (2)–at the suboccipital muscle insertions; Low cervical (2)–at the anterior aspects of the intertransverse spaces at C5 to C7;Trapezius (2)–at the midpoint of the upper border; Supraspinatus (2)–at origins, above the scapula spine near the medial border; Second rib (2)–upper lateral to the second costochondral junction; Lateral epicondyle (2)–1 cm distal to the epicondyles; Gluteal (2)–in upper outer quadrants of buttocks in anterior fold of muscle; Greater trochanter (2)–posterior to the trochanteric prominence; Knee (2)–at the medial fat pad proximal to the joint line

Ayurvedic Treatment of Fibromyalgia
The Caraka Samhita Sūtrasthāna chapter 13 famously elaborates on the preeminence and primacy of the Vata dosha in the human being. Caraka tells us that Vata is the subtlest substance of the body penetrating as a life force everywhere in the physiology. Furthermore, it sustains, activates and coordinates the sensory and motor organs.
The treatment of fibromyalgia, which is primarily a vātavyadi disease, focuses on both Vāta samshamana (re-balance) and samshodhana (purification) of the nervous and musculo-skeletal systems which become deranged due to accumulation of ama (toxins).

Panchakarma Therapy
This is the main physiotherapeutic process employed in this disorder and ideally is the initial intervention in fibromyalgia if the patient has no contraindications in which case it is deferred. Although treatments need to be customized for each patient, the general highlights include the following:
~Nirgundi tailam as sarvābhyanga ~Bāspa Sweda/Samstra Sweda herbalized with nirgundi ~Madana phalam churna + yastimadhu churna as vamana ~Kalkas (pastes) of sariva, neem, nirgundi, (12 g each mixed with 75 ml milk + 30 ml ghee) + ½ cup cooked yellow mung dal + shuddha tankana (borax) as lepa ~Brahmi or Bala tailam as shirodhara ~Shigru tailam (Moringa oleifera) or anu tailam as shirovirechana ~Prasarani tailam or Bilva tailam as anuvasana basti

Diet and Nutrition
The diet normally advised for patients of fibromyalgia is a modified Vata-pacifying diet. It should include (pathyam):
 Vegetable juices and soups.
 Coconut water and Coconut milk.
 Juice of carrot (33%), water (33%), ginger root (1 inch), garlic (1 clove), beetroot (1), spinach (handful), red pepper (1).
 Cooked vegetables including: squashes, zucchini, yam, tomato and pumpkin .
 Ample cumin, coriander, black pepper, ginger asafetida, garlic, fennel and turmeric.
 Moderate quantities of green salads with dressing of lemon juice, olive oil and a small amount of salt.
 Kichadi (recipe made by cooking white basmati rice and mung dal, 1:1 or 2:1 proportion)
 Warm milk with warming spices including cinnamon, cardamom, ginger and clove

Fibromyalgia patients should reduce (but not eliminate) the following food articles (apathyam) and behaviors:
 Hot (spicy) and fried foods; processed sugar; very bitter and astringent foods like brussels sprouts, cabbage, cauliflower, spinach, broccoli rabe and potatoes.
 Reduce the quantity of raw foods to <20% of the diet
 Excessive black tea, coffee, alcohol, yogurt, chocolate, cocoa.

Ayurvedic Herbal Medicines

*Please always seek guidance from a qualified Ayurvedic Physician for individualized regimen and dosage schedule before taking any Ayurvedic medicines.*

Dashamularishtam 15ml (1 Tbsp) 2X/day

Turmeric churna +Triphala churna (50:50 combination) ½ teaspoon 2X/day

Shuddha (pure) guggulu (Commiphora mukul) as 70% 5:1 hydroalcoholic extract 25 drops 3X/day

Kaishore guggulu as 70% 5:1 hydroalcoholic extract 25 drops 3X/day Vāta + Pitta reduction)

Yogaraj guggulu as 70% 5:1 hydroalcoholic extract 25 drops 3X/day (Vāta + Kapha reduction)

Triphala guggulu as 70% 5:1 hydroalcoholic extract 25 drops 3X/day (Vāta + Kapha reduction)

Chyawanprash 1 tsp 2X/day

Āmalaki churna (Emblica officinalis) 3 grams added to 3-6 oz. warm milk + 1 tsp honey

Nāgakesara [flowers] (Mesua ferrea) 2 grams with warm water 3X/day or as 40% 5:1 hydroalcoholic extract 25 drops 3X/day

Herbal mixture (I):
Guduchi (4 parts) Pippali (3 parts) Kantakari (2 parts) Dhanyaka (1 parts) Tulsi (2 parts) Maricha (1 parts)
45% 3:1 hydroalcoholic extract 25 drops 3X/day

Herbal mixture (II):
Ashwagandha (4 parts) Vidari (3 parts) Shatavari (2 parts) Pārijāta (1 parts) Nirgundi (2 parts) Chitraka (2 parts) 50% 3:1 hydroalcoholic extract 25 drops 3X/day

Nāgara Yastimadhu Haldi Nirgundi Kwath (Ginger Licorice Turmeric Nirgundi Tea) is a good alternative to NSAID’s or aspirin to relieve minor aches and pains. Steep 1 teaspoon each of these four powders in 5-7 ounces of hot water for 10 minutes. Strain. Consume 2 cups /day.
[Licorice root has anti-inflammatory actions comparable to cortisone, but without the harmful side-effects. Caution: If overused (>4 cups daily), licorice can elevate blood pressure and reduce serum potassium. Do not use this herb on a daily basis for more than seven consecutive days and avoid it if you have high blood pressure. After seven days simply eliminate it from this formula]

Lifestyle Shifts
 Avoid extended periods of worry, anxiety, fear, stress and grief.
 Sleep no less than 7 ½ hours each night.
 Perform gentle self-Abhyanga with warm Narayana or Vishagarbha oil mixed with sesame oil (50:50) daily; as minimum: apply to feet at night for 1 hour.
 Sip hot water frequently throughout the day (ushnodaka); drink approximately 4 cups/ day.
 Leave the house for minimum periods of 20 minutes each day.
 Anuloma-viloma pranayama for 5 minutes daily followed by 15 minutes shavāsana.

Conclusion
Many patients diagnosed with fibromyalgia can be helped by improved nutrition, appropriate and professional detoxification procedures, proper exercise, and special Ayurvedic herbal preparations. As more Ayurvedic physicians turn their attention to this disabling syndrome, the future prognosis is now improving for those affected by fibromyalgia. In addition, recent scientific studies suggest that specific areas of the brain and specific neurochemicals (i.e. substance P, endorphins, nerve growth factor) may be involved in the pathophysiology of fibromyalgia and research in these areas are ongoing.

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