Wednesday, December 21, 2011

Fibromyalgia and Mitochondrial Dysfunction

Dr Myhill on Fibromyalgia and Mitochondrial Dysfunction
by Sarah Myhill, MD*
December 21, 2011

Dr. Sarah Myhill is a UK-based physician with a special interest in fatigue and nutrition. Her pioneering research (“Chronic Fatigue Syndrome and Mitochondrial Dysfunction”) suggests the cells’ energy generating mitochondria are dysfunctional in ME/CFS – a situation that can produce various symptom clusters, including: a) blood flow/vascular abnormalities such as orthostatic intolerance, b) the widespread pain and sensitization most typical of fibromyalgia syndrome, and c) fatigue, exhaustion & brain fog. This information is excerpted with kind permission from (*


Fibromyalgia – Possible Causes and Implications for Treatment

The word ‘fibromyalgia’ just refers to a symptom - it means pain in the muscles. It occurs very commonly with chronic fatigue syndrome [ME/CFS] because I suspect the underlying causes are similar.

How Energy is Produced in Cells

All cells require energy in order to work. There are two ways that they can get their energy.

Energy Production Using Oxygen. Normally, energy is supplied to cells by mitochondria (little organelles within cells) which supply energy in the form of Adenosine Triphosphate (ATP) via a process called Oxidative Phosphorylation. This process requires oxygen, is extremely efficient, and is the way in which the vast majority of energy is produced the vast majority of the time. You might enjoy watching a very interesting presentation on oxidative phosphorylation (which starts with NADH and Ubiquinol CoQ-10) - published on the website of Purdue University, Indiana.

Energy Production Using Sugar. The second way in which cells can get energy is through Glycolysis.  From an evolutionary point of view this is a very much more primitive way of supplying energy. It does not require oxygen, it just needs sugar. It is extremely inefficient and the result of glycolysis is the production of large amounts of lactic acid.

All athletes recognize the moment when they switch from aerobic metabolism (requiring oxygen) via mitochondria to anaerobic metabolism (glycolysis) resulting in a build up of lactic acid. It is this build up of lactic acid that causes the pain, heaviness, feeling exhaustion, deadened muscles, and muscles will not work or go any faster sensation.

I am also interested in this idea because in horses there is a condition known as azoturia (tying up), which does not have an obvious human parallel. I suspect, however, that this parallel is fibromyalgia. This condition occurs in some susceptible horses when there is a huge build up of lactic acid in their muscles which causes extremely severe muscle damage, massive amounts of pain and distress and in severe acute cases the horse can die from it.

So What Goes Wrong in Fibromyalgia?

I suspect that in fibromyalgia there is an inappropriate switch from aerobic mitochondrial production of energy (via oxidative phosphorylation) to glycolysis (very inefficient anaerobic production of energy, not requiring oxygen, but with a large build up of lactic acid).

Lactic acid in the short term causes immediate muscle pain. Normally this is remedied by the person slowing down or stopping because of that pain, cells switch back into aerobic metabolism and the lactic acid is quickly cleared away and got rid of. All athletes know that when they stop running the horrible painful sensation in their legs will be gone within a few seconds or minutes.

This does not happen in fibromyalgia because:
• The sufferer can't make ATP quick enough to shunt lactic acid back to acetate (via the Cori Cycle, aka Lactic Acid Cycle; more on this below).

• And the sufferer is completely pole axed by ongoing lactic acid burn with inability to move,

• And possibly secondary damage from lactic acid which, for example, is good at breaking down the collagen matrix which holds cells together. That is to say, the lactic acid may cause microscopic muscle tears, which would present as local areas of soreness and would trigger a process of healing and repair by the immune system.
There would also be excessive release of free radicals as the immune system repairs. This may well cause further muscle damage and - in people with poor antioxidant system - this is a disease amplifying process. Some sufferers find vitamin B-12 helpful, possibly because it is acting as a scavenger of free radicals.

1. The most obvious reason for this of course is mitochondrial failure, which I believe is a major cause of chronic fatigue syndrome.

If mitochondria cannot supply sufficient energy to cells, cells will switch into glycolysis with a resultant build up of lactic acid. In the heart, this switch into anaerobic metabolism because of mitochondrial failure will present with angina (chest pain). There are many causes of mitochondrial failure (see handout - causes of CFS, mitochondrial failure and mitochondrial function test) such as:
• Lack of nutrients for mitochondria to work (D-ribose, magnesium, vitamin B3 (niacin), co-enzyme Q10 and acetyl L-carnitine). [Note: A trial due to start in early 2012 at Columbia University will test the ability of selected nutraceuticals to help manage lactate levels and other aspects of mitochondrial dysfunction in ME/CFS.]

• Toxic stress (which is blocking oxidative phosphorylation, or blocking translocator protein function),

• Poor antioxidant status (so mitochondria are damaged by biochemical activity),

• Poor hormonal control (poor levels of thyroid or adrenal hormones) and so on.
2. Lack of oxygen to muscles may be another reason for the switch to glycolysis.

A fascinating paper in the Lancet by John Yudkin explains how a high carbohydrate diet could cause high blood pressure. [As a long-time professor of nutrition and dietetics at the University of London, he was an early advocate of low carb Atkins-type diets]. Dr. Yudkin demonstrated that high levels of sugar in the blood were very damaging to muscles, and the body compensates for this by shutting down the blood supply to muscles when blood sugar levels are running too high.

Whilst this protects muscles from damage by sugar, it restricts oxygen supply to that muscle. One can see how if that muscle were asked to suddenly work quite hard, it would rapidly switch into glycolysis with production of lactic acid.

Therefore I suspect high carbohydrate or high sugar diets are a risk factor for fibromyalgia. In horses with azoturia, a high carbohydrate diet is a known risk factor.

3. Exercise - too much or too little!

Muscles are extremely dynamic organs. Blood is obviously supplied to them by the heart. However, for blood to come out of muscles requires the muscle itself to contract.

Thanks to a serious of valves within veins, when muscles contract they squeeze the blood out of themselves; then as they relax, the muscles fill with blood from the heart; and then as they contract, the blood is pumped out of them again.

Indeed, during exercise, it is this alternate muscle contraction and relaxation that is largely responsible for the circulation of blood through the muscle. That is to say, the muscles like being worked - it is essential for good blood supply and it is essential to move out and excrete toxins (such as lactic acid), which inevitably build up in muscles when they are being used.

The problem for people with fatigue syndromes is that they do not have sufficient energy to exercise their muscles and therefore bring an adequate blood supply to their muscles, and this alone causes muscle problems.

This is compounded in severe CFS where cardiac output is poor because of mitochondrial failure in heart muscle! For example, if there is too much build up of toxins in muscle, the reflex response of that muscle is to go into spasm. If that muscle goes into spasm and remains in spasm (i.e., a cramp), then the circulation is further impaired and there is sudden and quick build up of toxic metabolites, which causes more pain and spasm.

This is exactly what happens in horses with azoturia (hence its other name 'tying up'). There is so much muscle spasm and pain that the horse is literally unable to move and there is a huge amount of tissue damage going on.

Obviously humans do not push themselves to the extremes that horses do and so we do not see this same acute clinical picture, but I suspect the underlying biochemistry is the same.

4. The Cori Cycle (aka Lactic Acid Cycle)
• In converting glucose to lactic acid, 2 molecules of ATP are produced.

• To get rid of lactic acid, it has to be converted back to glucose, but this requires 6 molecules of ATP.

• When energy in the form of ATP is in such short supply, lactic acid hangs around much longer and is more damaging.
Implications for Treatment

1. Treatment of mitochondrial failure as per handout.

My experience so far is that:
• This works reliably well, though it takes months to respond, not weeks.

• But improvement is sustained month on month.

• What gets in the way is allergy - that is to say, tolerating the supplements.
2. Eat a low carbohydrate, low sugar diet.

Most calories should come from protein, fat and complex carbohydrates requiring gut fermentation by probiotics - these ferment carbohydrates into short chain fatty acids, which are the desirable fuel for mitochondria.

3. The muscle problem.

There is a fine balance to be judged here! When the muscle is in acute spasm and in pain, the worst thing you can possibly do is to exercise it because it will simply make everything much worse. However, the muscle does require blood circulation in order to heal and repair, and this can be encouraged by:
• Muscle relaxants (such as diazepam),

• Improving trace mineral status (imbalance of magnesium, calcium, sodium and potassium can cause a tendency to cramp and muscle spasm),

• Heat (to improve blood supply),

• And ideally massage or toning tables. The idea here is that the muscle is gently and rhythmically squashed, which therefore improves the circulation of the muscle, but without the muscle having to do any work.

• Painkillers may be helpful because the body's response to pain is muscle spasm.
However, if the muscle feels completely fine and is not painful at all, then it should be exercised gently on a daily basis. Obviously, the more exercise one can tolerate the better, but as soon as it switches into pain, you must stop or you simply make the situation much worse.

Gentle daily use of the muscles, therefore, improves the circulation and helps the muscle to clear toxic metabolites which trigger the above problems. This may be why yoga or Pilates exercises are often helpful in fibromyalgia.

However, do not use painkillers to allow exercise - this may make things much worse!

4. Improve antioxidant status.

As soon as muscle starts to become painful and release toxic metabolites, there is secondary muscle damage by free radicals. Having good antioxidant status helps protect against this secondary damage. The obvious antioxidants to measure which I check on a regular basis are: Co-enzyme Q10, glutathione peroxidase, and superoxide dismutase. [See "A Primer on Antioxidants and Free Radicals."]

There is one antioxidant which has been trialed in horses with good results called astaxanthin, and the dose for humans would be 4mg daily. [See “Astaxanthin – A little-known but power-packed nutrient.”]

5. Iodine deficiency.

This may present with fibromyalgia. [See “Iodine – What is the correct daily dose?”]

Monday, December 19, 2011

Physical Therapy for chronic pain

KALISPELL, MT., (PRWEB) December 19, 2011 

While many people associate physical therapy solely with injury rehabilitation, Professional Therapy Associates analyzed its physical therapy services to determine the percentage of patients undergoing rehabilitative therapy versus other forms of treatment. The Northwest Montana physical therapy practice found that approximately half of its patients are receiving treatment for injury, illness or post-surgery rehab, while the remaining half are using physical therapy to address a variety of other conditions or attain health, fitness and lifestyle goals.

“Physical therapy is widely recognized for its effectiveness in helping patients recover and regain full mobility after an injury, severe illness or surgery. However, it’s a common misconception that physical therapy is only used for rehabilitative purposes – statistically, one in two patients visit us for reasons other than rehab,” said Blaine Stimac, owner and CEO of Professional Therapy Associates. “Our physical therapists are experts at rehab therapy, but they also treat patients for conditions ranging from chronic pain, arthritis and repetitive strain to headaches, sleep problems and balance issues. They also provide strength, flexibility and endurance training to athletes and individuals looking to improve their overall health and fitness.”

Physical therapists undergo extensive training in biomechanics and the musculoskeletal system, which is why they are qualified to help patients increase mobility, alleviate pain and improve fitness. Stimac elaborated on some of the physical therapy services his team provides beyond injury and surgery rehabilitation:
  • Back Pain – “Many people immediately think of chiropractors when they have back pain, but physical therapy can effectively treat back pain as well as pain in adjacent areas, such as the neck, shoulders and hips,” explained Stimac. “Some people find that their back pain returns even after being treated by a chiropractor. This often happens when a chiropractor is correcting the issuing but not providing the necessary stabilization. This is where a physical therapist can help.”
  • Arthritis – Stimac notes that individuals with arthritis often have stiff joints because they avoid movements that may exacerbate their pain. However, by not moving or exercising those joints, arthritis sufferers often find the pain and stiffness only get worse. Physical therapists can teach patients exercises that will minimize pain and stiffness, and strengthen muscles that support the joints.
  • Desk Pain – Professionals who work with computers or at a desk often suffer from a host issues as a result of sitting for hours in a fixed position and performing repetitive movements. Physical therapy can assist with many different types of work-related pain – from back pain and neck stiffness to headaches and repetitive stress injuries. Not only will physical therapists help to ease patients’ pain, but they will also demonstrate how to avoid related problems in the future.
  • Sleep-Related Issues – According to Stimac, many individuals experience fatigue or have difficulty sleeping as a result of chronic pain. Conversely, there are others who may sleep well but in awkward positions that cause neck and shoulder pain during their waking hours. He explains that physical therapists are skilled in determining the cause of such conditions, and can provide treatments, exercises and advice that will help resolve the issue.
“When patients come to us with chronic pain or other complaints, we’ll identify the underlying cause, alleviate their pain or discomfort, and show them how to fix whatever is creating the problem in the first place,” said Stimac. “I would encourage anyone experiencing pain, stiffness or limited mobility to schedule a physical therapy evaluation. Montana residents can request a free consultation at any of our four Flathead Valley physical therapy clinics if they’d like to learn more about our treatments and explore whether physical therapy is the right choice for them.”

For additional information on Professional Therapy Associates – including details on its rehabilitative treatments and other physical therapy services, as well as contact information for its clinics in North Kalispell, Downtown Kalispell, Whitefish and Columbia Falls – please visit

About Professional Therapy Associates and Blaine Stimac

Professional Therapy Associates (PTA) is an established provider of physical therapy in Montana. Founded in Kalispell in 1988, the practice has expanded to include four convenient locations throughout Flathead Valley. In addition to its flagship Kalispell North facility, PTA also has clinics in Downtown Kalispell (Flathead Health and Fitness), Whitefish (The Wave) and Columbia Falls (Columbia Falls Clinic). Owner and CEO Blaine Stimac is a licensed Physical Therapist in Montana, and holds a Master of Science in Physical Therapy from the University of Montana. He and his team offer a full range of services, including manual physical therapy, sports medicine, therapeutic exercise and biofeedback, as well as treatment for back and neck injuries, motor vehicle injuries and work-related injuries. For more information, visit