Connecting Gut Dysfunction with Fibromyalgia

Fibromyalgia (FM) 

Fibromyalgia is a medical condition characterized by widespread pain. It is also associated with heightened pain response to normal pressure. While one of the main characteristics of Fibromyalgia is widespread pain, many people with FM also suffer from fatigue, sleep, memory, GI distress, and mood issues.  Fibromyalgia is one of the most common chronic pain conditions. It is estimated this disorder affects 10 million people in the US and an estimated 3-6% of the world’s population. Fibromyalgia is most common in women, and it also occurs in men and, in some cases, children. There also seems to be a genetic component to Fibromyalgia as several links to FM have been linked to family history. (1)

Diagnosing Fibromyalgia

Diagnosing Fibromyalgia can be tricky. To date, there is no current specific lab value that can directly link to the debilitating fibromyalgia diagnosis. In the past, Doctors diagnosed FM on a tender point test adopted from the American College of Rheumatology. On this test, if 11 out of 18 spots had to test positive for tenderness or pain, this would lead to a diagnosis of fibromyalgia.

_{Picture from the criteria established from The American College of Rheumatology 1990. Criteria initially established a foundation for plausible diagnosis of Fibromyalgia.}

While the above trigger points can be useful for helping a diagnosis of fibromyalgia, they’re not all-inclusive. Another problem with the tenderness spot test is that these trigger point areas can be sensitive or painful from numerous things (working out, dehydration, lack of sleep, etc.) and making an objective diagnosis difficult based on subjective findings. Diagnosis of fibromyalgia is usually a “diagnosis of exclusion.” For example, a doctor will rule out every other possible differential diagnosis before coming after a patient having fibromyalgia (3). For example, a doctor will take a history of your symptoms, including fatigue, widespread pain, bowel issues, muscle pain, and more, to diagnose fibromyalgia after ruling out other major diseases from the history exam and lab analysis. 

While there are several different hypotheses for causes of fibromyalgia including mitochondrial dysfunction, oxidative damage, physical injury, arthritis, stress, giving birth, chemical imbalances, brain or spinal cord injury, and more, to date, there is no clear-cut pathway that leads to the progression of this debilitating pain syndrome named Fibromyalgia. What if, by looking at what causes another gut disorder, we could also find new treatment strategies to help with Fibromyalgia?

Could an overgrowth issue (SIBO) be the culprit of your FIbromyalgia symptoms?

— Robert Fredrickson DNM, DC (@DrRfredrickson) May 30, 2021

Different types of probiotics for different clinical applications

In 2021, I have been diving into the research surrounding the differences in two classes of probiotics- Soil/Spore based probiotics and Commensal probiotics. While researching the mechanism of soil-based probiotics, there are actually many great studies showing their clinical use for the treatment of SIBO. SIBO (Small Intestinal Bacterial Overgrowth) is theorized as the translocation of colonic bacteria (bacteria in the large intestine) translocated into areas of the small intestines. SIBO is known to cause symptoms of gas, bloating, cramping, pain, indigestion, early feelings of fullness, diarrhea, constipation, cramping, and more. Some individuals also find that regular probiotics also produce more GI discomfort. This is possibly due to regular probiotics adding to more overgrowth of the small bowel. This finding of bloating from regular probiotics could also lead to a decision to try a course of Spore Based Probiotics to try to balance the overgrowth (SIBO) dysbiosis.

SIBO Potential causes

SIBO like fibromyalgia has some difficulties testing for an accurate diagnosis. But some proposed mechanisms for causes of SIBO include:

• Slow Motility-muscular peristaltic activity of the small intestines is dysfunctional and doesn’t fully allow feces and waste to be normally excreted properly.
• Hypochloridia-low stomach acid- leads to an improper breakdown of pathogenic bacteria and doesn’t fully digest macro and micronutrients.
• A dysfunctional immune system: doesn’t allow for proper identification of harmful pathogens
• pH changes in the small bowel
• Anatomy or bowel resection issues
• Unresolved IBS or other bowel disorders
• Irregular or inconsistent bowel movements
• History of long term antibiotic use

It’s also interesting to note that in a 2017 study they found that over 70-80% of IBS patients had a correlation with SIBO.

FIBromyalgia/sibo connection

Fibromyalgia patients routinely suffer from extreme muscle and joint pain but also have associated GI-related issues. I recently came across a few articles directly connecting fibromyalgia to SIBO. This is exciting! Could treating the root cause of what causes SIBO also help us to get the root cause of fibromyalgia?

Let’s look into what the literature says. The study I am highlighting is from the B&J journal- Annals of Rheumatic Diseases. This 2008 study found that 42 out of 42 fibromyalgia patients ALL had correlated cases of SIBO. What’s more, is they studied the amount of pain from fibromyalgia and found that the more pain fibro patients had, the more overgrowth (SIBO) was indicated by their hydrogen breath test.

How does SIBO cause pain in the body?

Studies looking at the effects of bad bacteria (gram-negative) that carry known endotoxins like lipopolysaccharide (LPS) have been shown to increase pain (hyperalgesia) in animal models (13). When bad bacteria has translocated or moved to areas in the small intestines in higher amounts not normally seen (SIBO), this has been shown to increase both liver and systemic inflammation. This also explains why higher amounts of overgrowth of bad bacteria, showed greater amounts of pain in moderate to severe fibromyalgia patients. (5)

So is SIBO causing Fibromyalgia, or is Fibromyalgia a result of unresolved SIBO? (11). And why aren’t all fibro patients being evaluated and treated for GI issues as the standard of care? (11)

It’s the chicken or the egg scenerio. Here are a few thoughts and obersations.

Research on Fibromyalgia patients will show a majority of fibro patients are taking NSAIDs for pain. This study confirmed that over 2/3 of NSAID users would have some degree of intestinal permeability (IP), aka leaky gut, mucosal toxicity (protective barrier), mitochondrial toxicity, and over-activation of the immune system (10). So what this means is that a counter pain medication actually leaves your gut vulnerable to leaky gut issues. Could chronic use of NSAIDs be a contributing factor to SIBO as well?

While the above study over NSAIDs will certainly leave fibromyalgia patients frustrated about what they can do for their pain if NSAIDs are potentially making their gut issues worse. If they take the NSAIDs to help with the pain, they are left with other harmful effects on their gut. What is the person to do? First, don’t stress yourself out more! Stress only makes the pain worse through the over-activation of the sympathetic nervous system. Know, there are natural options that can help. I will highlight some of my favorite vitamins and botanicals below to help support painful Fibromyalgia while also treating the underlying GUT dysfunction.

A New Alternative to Supporting Patients with Fibromyalgia

Consider the following suggestions below for a possible SIBO/FIBROMYALGIA support protocol. This should be done for 3-6 months under the supervision of a doctor.

• Rifaximin (anti-biotic) need RX for SIBO
• Spore/Soil Based probiotic organisms for a course of 3-6 months
• Low FODMAP diet
• Motility support-artichoke, ginger, etc
• Nonfermentable prebiotics-“flavo biotics”
• Natural anti-microbials
• BioFilm disruptors 1-2months
• Mitochondrial Support Products
• Digestive Enzymes to increase stomach acidity before meals. Can also use diluted apple cider vinegar before meals as well.
• Magnesium and Malic Acid- from food and supplements combined (goal 500mg-800mg daily for women)
• Full Spectrum Turmeric for natural pain relief 500mg-1000mg daily
• Antioxidants: Vitamin C and L-Glutathione
• Stress management
• Quality sleep-7-8 hours minimum.
• *Important to note that if SIBO suspected, use SPORE-based probiotics first, then after 3-6 months transition back to normal diet along with commensal conventional probiotics in order to maintain optimum microbial diversity.

_{*Disclaimer* For information purposes only. We always advise working with your personal health care provider for individualized personal care. Also, these are for supporting conditions, we are not tying disease states to treatments}

References

1. Prevalence of Fibromyalgia https://fibroandpain.org/prevalence-2#:~:text=The%20disorder%20affects%20an%20estimated,children%20of%20all%20ethnic%20groups.
2. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007 Jul 15;76(2):247-54. PMID: 17695569.
3. Fibromyalgia Diagnosis: How Doctors Diagnose Fibromyalgia Here’s what to expect at the doctor’s office when you suspect you might have fibromyalgia. www.creakyjoints.org
4. Ghoshal UC, Shukla R, Ghoshal U. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy. Gut Liver. 2017;11(2):196-208. doi:10.5009/gnl16126
5. Pimentel M, Wallace D, Hallegua D, et alA link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testingAnnals of the Rheumatic Diseases 2004;63:450-452.
6. Goebel A, Buhner S, Schedel R, Lochs H, Sprotte G. Altered intestinal permeability in patients with primary fibromyalgia and in patients with complex regional pain syndrome. Rheumatology (Oxford). 2008;47(8):1223-1227. doi:10.1093/rheumatology/ken140
7. Othman M, Agüero R, Lin HC. Alterations in intestinal microbial flora and human disease. Curr Opin Gastroenterol. 2008;24(1):11-16. doi:10.1097/MOG.0b013e3282f2b0d7
8. Cavalli G, Cariddi A, Ferrari J, et al. Living with fibromyalgia during the COVID-19 pandemic: mixed effects of prolonged lockdown on the well-being of patients. Rheumatology (Oxford). 2021;60(1):465-467. doi:10.1093/rheumatology/keaa738
9. Hannu T, Kauppi M, Tuomala M, Laaksonen I, Klemets P, Kuusi M. Reactive arthritis following an outbreak of Campylobacter jejuni infection. J Rheumatol. 2004;31(3):528-530.
10. Fortun PJ, Hawkey CJ. Nonsteroidal antiinflammatory drugs and the small intestine. Curr Opin Gastroenterol. 2005;21(2):169-175. doi:10.1097/01.mog.0000153314.51198.58
11. Is Fibromyalgia caused by leaky gut and SIBO? Chris Kresser 2019
12. Wallace DJ, Hallegua DS. Fibromyalgia: the gastrointestinal link. Curr Pain Headache Rep. 2004;8(5):364-368. doi:10.1007/s11916-996-0009-z
13. Walker K, Dray A, Perkins M. Hyperalgesia in rats following intracerebroventricular administration of endotoxin: effect of bradykinin B1 and B2 receptor antagonist treatment. Pain. 1996;65(2-3):211-219. doi:10.1016/0304-3959(95)00195-6