Affecting 2% to 5% of the population, fibromyalgia is a complex condition, the pathophysiology of which is incompletely understood.¹ Most of those affected are females and there is significant overlap with other pain conditions such as rheumatoid arthritis. The chronicity and complexity of fibromyalgia means that the path to recovery is often long and slow, requiring patience and persistence from practitioner and patient alike.

Initial Consultation

A 45-year-old female presented to clinic with a 12-year history of fibromyalgia. She reported that her symptoms started following spinal surgery to correct damage that had occurred during the delivery of her 2nd child. She was unable to work due to her inability to sit for long periods of time, or perform strenuous activities. A stressful relationship was also identified as a contributor to her ongoing health issues.

Case History:

• Energy levels varied between 3/10 and 8/10
• Chronic lower back and neck pain exacerbated by gardening, massage and acupuncture
• Tender points lumbar spine, ankles and mid-thoracic. Pain rated 6/10 most days and 10/10 with a flare
• Poor sleep, waking 4 to 5 times nightly and waking unrefreshed in the morning
• Obesity (BMI 38.4)
• Mood disturbances of flat depression
• Hay fever including sneezing and rhinorrhoea
• Cracked heels
• Poor wound healing
• Diet high in wheat, dairy, vegetable oils, and processed food, low in antioxidants
• Inadequate water intake <1 L daily
• Coffee consumption twice daily

Current Medication:

• Paracetamol - 2 tablets, twice daily
• Codeine phosphate with paracetamol (as required) - 2 tablets, twice, daily twice weekly
• Dosulepin hydrochloride - 75 mg/day
• Nortryptaline - 10 mg/day
• Magnesium compound containing 300 mg magnesium as oxide, citrate and amino acid chelate - 2 tablets daily

Initial Prescription

The aim of the initial prescription was to reduce pain and inflammation, improve sleep and energy, and to optimise her diet. Her prescription included:

• A herbal and nutritional powder providing 1.5 g Withania somnifera (withania), 300 mg magnesium (as citrate) and cofactors for sleep and mood. Dosage: 12 g twice daily with the second dose taken before bed.
• A herbal tablet containing 3.0 g Rhodiola rosea (rhodiola) and 600 mg Schisandra chinensis (schisandra). Dosage: 2 tablets at breakfast and 2 tablets at lunch.
• A nutritional powder containing 1.0 g ascorbic acid, 1.35 g lysine, 25 mg zinc (as citrate), and cofactors for immunity. Dosage: 5 g twice daily
• A nutritional powder containing 300 mg palmitoylethanolamide (PEA). Dosage: 300 mg twice daily

Dietary and lifestyle advice included:

• Reduce or remove wheat and dairy from the diet
• Aim for 5 servings of vegetables and 2 servings of fruit per day
• Consume 1 to 2 low mercury fish meals per week
• Follow a wholefood, anti-inflammatory or Mediterranean diet
• Increase water intake to 2 L daily
• Limit coffee to 1 daily
• Add three 15 to 20-minute gentle swimming sessions per week

She was referred to her general practitioner for assessment of her nutritional and hormonal status.

2-Week Follow-Up

The patient reported improved sleep with fewer waking episodes throughout the night. Her  energy had improved, and she rated it as 5-6/10 most days. She has also reduced the use of paracetamol from 2 tablets per day to twice weekly. She had made some dietary changes, however had not embarked on an exercise regime yet. She reported constipation, which she attributed to the zinc and vitamin C powder.

Her blood test results revealed:

• Ferritin 43 μg/L (reference range 30-250 µg/L)
• Urinary iodine 67 μg/L (reference range > 99 µg/L)
• TSH 4.5 mIU/L (reference range 0.3-3.5 mIU/L)
• T3, T4 and thyroid antibodies not tested
• Serum zinc 7.6 μmol/L (reference range 10-25 µmol/L)
• Vitamin D3 58 nmol/L (reference range > 49 nmol/L)
• Morning cortisol 220 nmol/L (reference range 100-535 nmol/L)
• Active B12 94 pmol/L (reference range >40 pmol/L)

Her prescription was updated as follows:

• An iron supplement containing iron 24 mg (as glycinate) and ascorbic acid 120 mg (as calcium ascorbate) was added. Dosage: 2 capsules every second day
• The zinc and vitamin C powder was replaced with a herbal and nutritional tablet for thyroid and adrenal support containing 400 mg Rehmannia glutinosa (rehmannia), 400 mg tyrosine, 50 mg ascorbic acid, 120 μg iodine (as potassium iodide), 15.1 mg zinc (as ascorbate), 50 mcg selenium (as selenomethionine), 1 mg cyanocobalamin, and cofactors. Dosage: 1 tablet twice daily
• Include 1 teaspoon of local raw honey to reduce hay fever symptoms

She was encouraged to include the prescribed exercise into her regime and continue a wholefood, anti-inflammatory diet.

6-Week Follow-Up

The patient reported feeling better than she had for several years, until the week prior where she had overexerted herself with yard work, resulting in a flare of pain. The following day she came down with a respiratory infection and then a sinus infection. She was prescribed antibiotics for the sinus infection and had ceased all other supplements. Prior to the pain flare and respiratory infection, her energy was consistently 6-8/10, she was only waking once per night, her pain score had declined to 4/10 and she had reduced her paracetamol intake to 2 tablets 1 to 2 times weekly. She had also ceased using codeine phosphate with paracetamol (until the pain flare when she required it again). She had not commenced exercising.

Her prescription was changed to include:

• A probiotic formula containing Bifidobacterium longum (BB536), Bifidobacterium breve (M-16V), Bifidobacterium infantis (M-63), Bifidobacterium lactis (BI-04), Bifidobacterum lactis (HN019), Lactobacillus rhamnosus (HN001), Lactobacillus paracasei (Lpc-37), Lactobacillus salivarius spp. salivarius (Ls-33), Lactobacillus casei (Lc-11). Dose: 1 capsule daily away from the antibiotics until the bottle was finished.
• A herbal nasal irrigation containing saline and 1 mL Hydrastis canadensis (golden seal) diluted in 30 ml of water to be used twice daily until sinus symptoms cleared.
• She was instructed to resume her previous prescription once she was feeling better and had completed the course of antibiotics.

20-Week Follow-Up

The patient’s symptoms continued to improve. She reported:

• Energy 6-8/10 most days
• Sleep, waking 0 to 1 times per night
• Pain 2-4/10
• Improved mobility
• Weight loss of 3.4 kg
• She had started walking 10 minutes per day 3 times weekly

Unfortunately, a visit to her general practitioner to discuss wounds that had failed to heal revealed a rare form of leukaemia requiring immediate hospitalisation. The patient was grateful for her improved health and nutritional status prior to the diagnosis, and although she discontinued most supplements on the advice of her oncologist, she occasionally consumed 500 mg ascorbic acid to support her white blood cell count.

Fibromyalgia is a complex and debilitating condition affecting many patients. This case is an example of the benefits that can be gained with dietary improvements and the correction of nutritional imbalances. While supplements alone cannot completely heal a patient, along with appropriate dietary and lifestyle changes, they can provide the elements required for energy production, pain reduction and good sleep quality – essential factors for fibromyalgia patients.

[1] https://www.healthdirect.gov.au