The Nutritional Supplement

32 year old Caucasian female with two goals:

• Better management of fibromyalgia – especially during pregnancy
• Prevent autism and optimise health of her current foetus

Fibromyalgia

• Diagnosed by her family physician 4 years ago (age 28)
• She originally experienced widespread pain and to her recollection she was evaluated, and found not to have: thyroid disease, anaemia, Lyme disease, or autoimmune disease.
• She was recommended to take acetaminophen as needed (she takes this most days) and magnesium daily.
• Pain is significantly aggravated with pregnancy (past and current)
• 2 months pregnant with second child
• Concerned as first child (now 2 years old) has autism
• She is concerned that either the fibromyalgia or the acetaminophen might have caused the autism to develop in her first child and is now worried about her current pregnancy

Review of Significant Symptoms:

Neurological:

• Insomnia (difficulty falling asleep with frequent waking)
• Anxiety (generalised and experiences occasional panic attacks)
• Frequent headaches –typically occiptal/frontal; 2 to 3 times each week

Musculoskeletal:

• Generalised achiness, soreness and pain to palpation; worse with pregnancy

Gastrointestinal:

• Typically experiences frequent 2 –3 bowel movements daily of loose consistency, although while pregnant, bowel frequency has reduced to once daily.

Gynaecologic:

• Gravida: 2, Para: 2. Hxof regular menses with 32 day cycle, 4 days of moderately heavy flow, moderate dysmenorrhea.

Endocrine:

• History of cold extremities -bilateral, mild fatigue for 15 years –worse during pregnancy

Family History:

• Father: alcoholism
• Mother: Migraine headaches, depression
• Sister: depression

Trauma History:

• History of physical abuse from her father from the ages of 10 to 15 years (parents divorced when she was 15 and her father moved away)
• Her only son (2 years old) is autistic. His main behaviors include:
• Poor eye contact, slow language development, and hand flapping

Diet:

• Nausea with pregnancy somewhat relieved by limiting her diet to rice, chicken and soup
• Drinks coca cola daily (relieves nausea) –normally does not drink soda
• Historically diet is mostly vegetarian, with some fish and chicken 1 to 2 times weekly. She cooks most food at home and estimates that 60% of her food is organic.

Exercise:

• Walks daily for 30 minutes at moderate pace

Medication & Supplements:

• Acetaminophen-extended release: 1300mg twice daily most days
• Magnesium 200mg daily
• Prenatal multivitamin (prescribed by her OB/GYN) –two daily

Findings of note:

• Fasting blood sugar = 96 (rr65-99 mg/dL)
• Fasting insulin = 22 (rr2-25 mIU/L)
• Cardiac C-reactive protein = 0.8 (rr<0.9 mg/L)
• Fibrinogen = 345 (rr200-400 mg/dL)
• Homocysteine = 9.2 (usuless than 9.0 mmol/L in PG woman)
• Serum B12 = 502 (rr243-894 ng/L)
• VitD,25OH = 29.4 (30.0 –74 ng/mL)
• TSH = 2.12 (rr0.15–4.50), free T3 = 2.8 (rr2.0 –4.8), total T4 6.2 (rr4.5 –12.5)
• Total cholesterol = 180 mg/dL
• ALT = 24 (7-56 u/L)
• AST = 26 (rr10-40 u/L)

Assessment Considerations:

• In order to diagnose fibromyalgia it is important to always look for a history of global (full body) pain, fatigue, and associated centrally-mediated symptoms, such as depression, anxiety, unrefreshed sleep, and irritable bowel syndrome.
• Use conventional labs to rule out organic medical conditions which may explain some of the symptoms [i.e., complete blood count (CBC), blood chemistry, comprehensive thyroid panel, iron, ferritin, sedimentation rate (ESR), c-reactive protein (CRP), viral antibody titres [EBV, CMV, etc.]), and depending on history and examination, autoimmune antibody panels, Lyme and co-infection testing].
• Use integrative and functional testing to rule out causes related to personalized alterations in biochemistry and metabolism to help explain symptoms (i.e., organic acid analysis, toxin panels, stool analysis, adrenal stress panels, etc.)

Insights, Tips and Perspectives:

• Make sure that patients who tell you that they have FMS really have a centrally-mediated global pain and fatigue syndrome with the expected comorbidities before that diagnosis is accepted and continued.
• If the patient’s presentation is not “classic FMS”, find out what is causing the patient’s signs and symptoms and diagnose the condition using proper terminology so that you can apply the most appropriate therapies
• Do not make the patient feel as if nothing is wrong with them if you have to inform them that their condition does not meet the diagnostic criteria of “classic FMS”. Instead, assure them that you will work to determine the real cause(s) and will address these causes in the most appropriate ways possible in order to assure the highest chance of successful recovery.

Management Considerations:

• In “classic fibromyalgia syndrome (FMS)” consider serotonin precursors and modulators [i.e., 5-hydroxytryptophan (5-HTP)], melatonin, and calming stress-response neuromodulators (i.e., GABA-nergic botanicals such as Valeriana officinalis, Passiflora incarnata, Scutellaria laterifolia, Melissa officinalis, Matricaria recutita, etc.), GABA, L-theanine, taurine, phosphatidylserine, calming adaptogens [Withania somnifera, Panex quinquifolius), and basic nutritional stress-repletion (i.e., vitamin C, magnesium, phosphorylated B vitamins, methylated folate, methyl- and adenosylcobalamin)
• In “classic FMS” consider medication as necessary, i.e., serotonin-norepinephrine reuptake inhibitors (SSNRI), alpha-2 delta ligands, gabapentinoids, GABA receptor agonists, and low-dose naltrexone.
• In “classic FMS” consider psychological counselling co-management, cognitive behavioural therapy (i.e., biofeedback, heart-rate variability training, Yoga, meditation, deep-breathing, progressive relaxation, etc.), stretching and mild exercise.
• Support and correct functional and personalized biochemical insufficiencies as necessary, including mitochondrial energy support (CoQ10, carnitine, ribose, etc.), thyroid nutritional support and/or hormone replacement therapy, and gastrointestinal dysbiosis and detoxification pathway support.