R. PAUL ST. AMAND, M.D.
4560 ADMIRALTY WAY, SUITE 355
MARINA DEL REY, CA. 90292
Phone: (310) 577-7510
(Reproduced with permission from the authors. Please note, some formatting edits were required to make this paper read-able ~Christine)
Fibromyalgia is a cyclic and a symptomatically progressive illness that affects millions of people regardless of race. It is manifested by many complaints that initially last only a few days, but are later unrelenting. Recurrent attacks eventually involve multiple body areas and systems until patients simply cycle from bad to worse. They are referred from doctor to doctor based on individual complaints. The partially-informed professional may fail to grasp the extent of the problem and thus divide the disease into symptom-packages that lead to medical dead ends such as chronic fatigue, systemic candidiasis, myofascial pain, irritable bowel, or vulvar pain syndrome. There are no diagnostic x-ray or laboratory tests for fibromyalgia.
The American College of Rheumatology recommends eliciting pain from at least eleven sites from eighteen predetermined “tender points” to confirm the diagnosis. Unfortunately, individual pain perception and tenderness vary greatly. So-called “chronic-fatigue” patients have high pain thresholds and are not particularly sensitive to finger-poking. They may feel stiff, but complain mainly of fatigue and cognitive impairment. We urge physicians to seek objective evidence and stop relying on purely subjective responses. The confirmation of fibromyalgia is more reliably obtained by using our method of palpation that we call mapping (see below).
Fibromyalgia has no set symptoms. Various combinations from the following list can be anticipated:
Central Nervous System: Fatigue, irritability, nervousness, depression, apathy, listlessness, impaired memory and concentration, anxieties and even suicidal thoughts. Insomnia and frequent awakening due to pain result in non restorative sleep.
Musculoskeletal: Swollen structures press on nerves to produce all types of pains especially morning stiffness. Any muscle, tendon, ligament or fascia in the face, neck, shoulders, back, hips, knees, ankles, feet, arms, legs and chest may participate. They also cause calf/foot cramps, numbness and tingling of the face or extremities. Old injured or operative sites are commonly affected. Fibromyalgia is erroneously considered non-arthritic even though joint pain, swelling, heat and redness are common.
Irritable Bowel: (Often called leaky gut, spastic colon or mucous colitis). Symptoms include nausea (usually transient, repetitive waves), indigestion, gas, bloating, deep pain, cramps, alternating constipation and diarrhea sometimes with mucous stools.
Genitourinary: Mostly affecting women are pungent urine, frequent urination, bladder spasms, burning urination (dysuria) with or without repeated bladder infections and interstitial cystitis. Vulvodynia (vulvar pain syndrome) includes vaginal spasm, irritation of the labia (vulvitis) or deeper (vestibulitis) that induce painful intercourse (dyspareunia) all without the typical cottage-cheese discharge that accompanies yeast infections. Fibromyalgia is worse premenstrually as are PMS and uterine cramping.
Dermatological: Various rashes may appear with or without itching: Hives, red blotches, itchy bumps or blisters, eczema, seborrheic or neurodermatitis, and rosacea. Skin is dry and nails are brittle or easily peel; hair is of poor quality and often falls out prematurely. Strange sensations (paresthesias) are common such as cold, burning (especially palms, soles and thighs), crawling, electric vibrations, prickling, super-sensitivity to touch, and flushing often with sweating.
Head, Eye, Ear, Nose, and Throat: Headaches (migraines), dizziness, vertigo (spinning) or imbalance; itchy, burning and dry eyes or lids sometimes produce morning sticky or sandy discharges; blurred vision; hayfever or nasal congestion and post-nasal drip; painful, burning or cut-tongue sensation, scalded mouth and abnormal tastes (bad, metallic); intermittent low-pitched sounds or transient ringing in the ears (tinnitus); ear and eyeball pain; sensitivity to light, sounds and odors (perfumes or chemicals).
Miscellaneous Symptoms: Weight gain; mild fever; reduced immunity to infection; fluid retention with morning eyelid and hand swelling that gravitates to the legs by evening, stretches tiny tissue nerves to produce restless leg syndrome; adult-onset asthma.
Hypoglycemia Syndrome: This is a separate entity that may affect thirty percent of female and fifteen percent of male fibromyalgics fibroglycemia). Sugar craving, tremors, clamminess, anxiety, panic attacks, heart pounding, headaches and faintness induced by hunger or by eating sugar and starches (carbohydrates) are solid clues for diagnosis. Hypoglycemics must follow a prescribed diet or they will not fully reverse symptoms that strongly overlap those of fibromyalgia.
Though Fibromyalgia is almost always inherited, injury, infection surgery, and stress may prod susceptible individuals into overt attacks. We have seen patients as young as age two as well as presenting in the seventies. Family histories often span three and four generations. Boys and girls are equally affected before puberty, but in adults, females heavily predominate (85%). Forty-five percent of adults remember “growing pains” in childhood that disappeared with the growth spurt of puberty. If untreated, we believe fibromyalgia evolves into ‘tartar of joints’ and the eventual damage of osteoarthritis.
Forty-seven years ago, a man taking a gout medication noticed he could peel calculus (a calcium phosphate compound) off his teeth with his fingernail. This mundane observation raised the possibility that tartar was a reflection of an unrecognized systemic problem expressed in saliva. I postulated a genetically defective enzyme prominent in the kidney that would cause a backup of phosphate throughout the system. Excesses of this ion in certain cell structures (mitochondria) would seriously impede the formation of energy (ATP). The resulting cellular fatigue would cause wide-spread malfunctions that would easily explain all the symptoms of fibromyalgia. Our paper for interested professionals defends that theory.
We treat fibromyalgia using guaifenesin. It increases urinary excretion of phosphate, gradually extracts abnormal body-wide accumulations, and thus reverses the illness. Guaifenesin is devoid of significant side effects and totally safe for children. It has been marketed for over fifty years for loosening and increasing the flow of mucus. Manufacturing processes seem to determine its potency, effectiveness and duration of action. We monitor and recommend the brands that have proven adequate for our purposes. Excessively short-acting tablets lack twenty-four hour action. Combination long-short formulations may fail due to insufficient contents of either component. We determine what works for individuals by sequential physical examinations (next paragraph). Treatment is begun using reliable products at 300 mg twice daily for the first week. The drug has no significant side effects so that worsening symptoms suggests that is the correct dosage for reversal, an amount that works for only 20% of patients. If there are no significant changes that first week, we raise the dosage to 600 mg. twice daily and hold there until the next examination. The response rate at this amount is 80%. Obviously, 20% of patients will need further adjustments. We repeat the muscle examination monthly (see below) until sufficient areas disappear to confirm the adequacy of dosage. Symptoms frequently intensify during the clearing process and new ones may surface due to increased intensity. This confirms that purging is underway because guaifenesin has no side effects. Better hours eventually cluster into days and finally weeks. During this process, lesions objectively soften upon examination, sometimes split, and gradually vanish. Recovery is rapid compared to the time it took to develop the illness. Even the slowest responders clear at least one year’s accumulated debris every two months. The earliest lesions are the last to clear.
The original description of fibromyalgia as “rheumatism with hard and tender places” has been forgotten. The often-recommended tender-point exam seeks subjective patient pain sensations from eighteen predetermined areas. It is of limited value compared to objective, sequential body examination (mapping) that helps establish the dosage and document disease reversal. We examine musculoskeletal tissues using the pads of our fingers to feel muscles, tendons, and ligaments. With practice, multiple swollen places become obvious. We sketch their location, size and degree of hardness on a caricature that becomes our baseline for future comparisons (figure 1). Hands should move as if to iron out wrinkles in the underlying tissues. Expressions of tenderness do not influence findings. The most important site for confirming the diagnosis and establishing the dosage is the left thigh. The outside of the quadriceps muscle (Vastus lateralis) and the front part (Rectus femoris) are involved in 100% of adults; they clear within the first month of proper treatment.
To ignore the following guarantees failure: aspirin and other sources of salicylate block the action of guaifenesin at the same kidney level as uricosuric medications. Salicylates are present in many pain medications such as aspirin and those for some forms of colitis. Almost all plant species have substantial levels of the natural chemical. Quantities vary from crop to crop and are stored to fend off infections and to help heal injuries. Salicylates are readily absorbed through intact skin as well as the thin membranes of the mouth and intestine. Products used topically or as medications should be thoroughly inspected for ingredients including synthetic forms such as octisalate in sunscreens. A person’s genetic makeup determines susceptibility to blocking. Nevertheless to assure success, everyone should adhere to the protocol and make no modifications.
No diet is required for fibromyalgia: the liver has a certain but limited capacity to counter food salicylates. It cannot however override excesses derived from plant concentrates obtained from juicing or in herbal medications.
Decongestants and cough medicines have side effects and should not be used as sources for guaifenesin. Pure guaifenesin has no side effects (rarely transient nausea) and no known drug interactions. Pain medications such as acetaminophen (Tylenol), Ultram, Darvocet-N, Imitrex, and non-steroidal drugs such as Advil, and Aleve, do not block guaifenesin. Especially when dealing with chronic illness, we chose not to prescribe narcotics such as codeine, hydrocodone (Vicodin), oxycontin, morphine or methadone even though they are not blockers. They are too liberally prescribed for pain control at the price of eventual addiction. When our mapping indicates it is time to discontinue them, intense withdrawal effects usually occur. All too many patients fail in the attempt since, as the drug wears off; the brain reproduces identical symptoms that once originated in outlying tissues.
Our treatment is not for the faint of heart. It demands a patient’s skill and determination with or without professional supervision. Remember, reversal of the disease reproduces past symptoms and can induce new ones. We repeat they are not side effects. Though the intensity of the early reversal may cause concern it is similar to a rollercoaster ride that gets progressively tamer. We offer hope to those with willpower to try once again despite previous failures. Meticulously done, this is a highly-effective protocol.
Fibromyalics with hypoglycemia must adhere to a low carbohydrate diet or they will not feel better, although guaifenesin will clear the disease. It is not mandatory for patients with carbohydrate cravings to do the same, but the diet will jump start energy if done for the first 30 days of treatment. Carbohydrates result in insulin release which induces kidney reabsorption of phosphate and drives it into various cells. Elimination of the following foods will prevent fluctuations of blood sugar, provide a surge in energy, improve cognition and can ease irritable bowel symptoms:
FOODS TO AVOID STRICTLY: Alcohol, caffeine, dried fruits, fruit juice, baked or refried beans, barley, black eyed peas, lentils, garbanzos, rice, bananas, pastas, flour tortillas, tamales, corn, potatoes. No sweets of any kind, including: dextrose, glucose, hexitol, maltose, sucrose, honey, fructose, corn or cane syrup or starch.
R. Paul St. Amand, M.D. Claudia Craig Marek, August 2007
Associate Clinical Professor Medicine Medical Assistant
Important: Do not assume fibromyalgia is the cause of all symptoms. When in doubt or confronted with new problems, please consult your personal physician or appropriate specialist.
(Interested physicians may contact us for technical material paper or consult the Technical Appendix in our book.) or click here
The American Journal of Medicine: Symposium: The Fibromyalgia/Fibrositis Syndrome. September 29, 1986.
The American Journal of Rheumatology: Fibromyalgia Syndrome, November 1989.
Starlanyl, Devin M.D. and Copeland, Mary Ellen: Fibromyalgia and Chronic Myofascial Pain Syndrome-A Survival Manual. New Harbinger Publications, Inc., 1996. www.sover.net/~devstar
Williamson, Miryam Erlich: Fibromyalgia: A Comprehensive Approach. New York: Walker and Co. 1996 and The Fibromyalgia Relief Book, 213 Ideas for Improving Your Quality of Life, 1999. www.mwilliamson.com
Winter, Ruth M.S.: A Consumer’s Dictionary of Cosmetic Ingredients. New York: Crown Trade Paperback, 1998.
St. Amand, M.D., R. Paul and Marek, Claudia: The Use of Uricosuric Agents in Fibromyalgia: Theory, Practice and a Rebuttal to the Oregon Study of Guaifenesin Treatment. Clinical Journal of Myofascial Therapy, Vol. 2, No 4, 1997
St. Amand, M.D., R. Paul and Marek, Claudia: A Description of Fibromyalgia and Hypoglycemia: Their Combined Morbidity and Therapy with Guaifenesin and Diet. AAEM Symposium Syllabus, 1998.