Tag Archives: chronic pain

Gluten sensitivity and fibromyalgia… is there really a link?

Marcusby Holistic Osteopath, Marcus Webb

By the time you read this little article I am sure you will have heard about a study linking gluten sensitivity with fibromyalgia and reporting on how ‘remarkable clinical improvement can be achieved with a gluten-free diet in patients with fibromyalgia (FM) even if coeliac disease has been ruled out’. The conclusion also goes on to say that ‘non-coeliac gluten sensitivity may be an underlying treatable cause in FM syndrome’.

However, the plot thickens; in all 20 of the FM subjects studied biopsies of their intestine revealed a pathological change known as intraepithelial lymphocytosis, a finding the authors use to help support their hypothesis that gluten sensitivity is a causal agent and underlies FM. This cause and effect relationship that this latest study hints at does sound convincing especially when we keep in mind that intraepithelial lymphocytosis has been associated with gluten sensitivity in the past but should we be jumping to such a definitive conclusion; what about those FM patients who don’t have intraepithelial lymphocytosis, were they removed from the study because they did not respond to a gluten-free diet? Don’t get me wrong, I am not trying to discredit or down play the study or the potential benefits of a gluten free diet in cases of FM but I am aware that many FM sufferers may read this and feel that they have to follow a gluten-free diet in order to get better but before going on it may be good to lay out a little additional information about intraepithelial lymphocytosis.

Within the tissue of the gut known as (epithelial tissue) special white blood cells known as lymphocytes reside waiting like guard on duty to be triggered into life by an invading army. In the case of the gut this is would normally be a bacterial infection. In around 3% of routine biopsies increased levels of lymphocytes can be observed (ie. intraepithelial lymphocytosis) and between 9-40% of cases celiac disease has eventually been diagnosed. In some cases intraepithelial lymphocytosis occurs in other multi-system disorders such as Hashimoto’s thyroiditis, Graves’s disease, rheumatoid arthritis, psoriasis, multiple sclerosis, Systemic lupus erythematosus, ankylosing spondylitis and autoimmune enteropathy. The other cases tend to be viewed as a non-specific finding related to other health issues such as bacterial overgrowth (SEBO), inflammatory damage secondary to non-steroidal anti-inflammatory drug use or other chronic inflammatory bowel disease. In other words, the presence of intraepithelial lymphocytosis is not diagnostic of gluten sensitivity but in the absence of other causes gluten sensitivity could be a possibility since it has been reported to account for around 10% of the cases of intraepithelial lymphocytosis but it should be kept in mind that hypersensitivity to other non-gluten components of food may also trigger this tissue change. Interestingly, a good number of the 20 subjects had co-existing health problems that have also been linked with the bowel tissue chances characteristic of intraepithelial lymphocytosis such as psoriasis (in 2 cases), hypothyroidism (in 3 cases), inflammarory/irritable bowel (in 5 cases) and gastric reflux (in 10 cases) which is a problem that commonly receives PPI drug therapy. As a drug class, PPI’s are also known to trigger intraepithelial lymphocytosis. However you critique this study as much as you want but what you can’t ignore is the outcome; for many, great relief of their chronic and disabling symptoms using a drug-free approach.

For many FM sufferers having a condition that is resistant to conventional therapies places them in a real corner when it comes to treatment and management options. From my experiences working with FM/CFS sufferers we tend to do what works or what works for that person! Science tends to take its time in catching up with the clinical observations but while it is catching up in many cases there is no real harm in exploring options that appear to have some evidence to support their use such as a trial of a gluten-free diet. From the results of the current study the gluten-free diet was followed for 16 months on average but in one case (a FM sufferer for 20 years) improvement in pain, fatigue and gut symptoms were felt after just 5 months and in another case (a sufferer for 10 years) complete remission of FM and improvements in gut and migraine was also observed after just 5 months. In some cases significant improvements and a return to normal life activities and work were seen after more prolonged (over 30 months) exposure to the gluten-free diet. However you look at it, cutting the gluten has made a dramatic difference to many sufferers in this small study.

If you feel that a gluten free approach is something you fancy trying its not a diet to be taken on lightly… so many foods contain gluten! Despite this, I would advise that you seriously consider going gluten free if your FM is of long standing and you have exhausted all other approaches. Keep in mind that you may have to stick to it for many months before you feel any tangible benefits but again, for what its worth, I can support the observations that many ill-defined inflammatory and pain related conditions simply improve with the elimination of gluten.

To help get you started you should avoid Barley, bulgar wheat, couscous, durum wheat, rye, semolina, spelt, wheat, all biscuits, breads, cakes, chapattis, crackers, muffins, pastries, pizza bases, muesli, wheat based breakfast cereals and anything made from wheat, rye or barley flour. By no stretch of the imagination is this a complete gluten free diet but it’s a start and something you can instigate today. Sitting down with an experienced nutritionist or naturopath should be your next step so you can get a more complete understanding of the complete gluten free diet and what it involves. In the early days of a gluten free diet I tend to recommend the use of a special dietary enzyme supplement based in a blend of plant derived gluten splitting enzymes. In addition to the cellulose digesting enzyme known as cellulase the key ingredient in Gluten Relief is Dipeptidyl Peptidase IV (or DPP-IV for short). DPP-IV is a type of protein splitting enzyme, known as a protease, and has been shown to break down the wheat protein gluten and milk protein casein. This combines with alpha-galactosidase to aid in the digestion of long chain sugars found in beans, broccoli, cabbage, sprouts etc… Using an enzyme preparation such as Gluten Relief (by the Canadian manufacturer Natural Factors) does not replace in anyway a gluten free diet but when you are unsure or are out and about with limited choices it may help to ‘defuse’ a potential gluten containing meal.

Link to study: Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. 

Link to Gluten Relief product


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Helping to combat fatigue and body-energy crises using D-ribose.

What frustrates many people who suffer from fatigue with or without the associated muscular pain known as fibromyalgia is the fact that, on paper, they are too well to be ill. Routine blood tests are typically normal in both situations but the level of pain and fatigue are far from normal and can be life destroying.

Back in August we posted a brief note on the research behind ribose and fatigue. In this post we take it a bit further and explain more of the detail.

It is true to say that there is no known cause for fibromyalgia with all laboratory tests including muscle samples (biopsies) taken from the most tender regions appearing perfectly normal on specialist examination and analysis. This lack of medical evidence places sufferers in a dilemma; how to manage the problem? Exciting work coming out of America is throwing new light on the issue. The latest in a number of small scale studies confirms what has been observed clinically. A simple sugar-like substance, known as ProRibose (contains pure D-ribose), can be of help. The study in question involved 41 sufferers and was set up to investigate the effects of D ribose on two key end points; improvements in pain relief and easing of fatigue. The average age of the study group was 48 years old and 78% were female. This is in keeping with the typical profile of a fibromyalgia and fatigue sufferer. As with many studies, some people dropped out before the test month was finished but of the 36 who completed the trial 69% reported significant improvements in both of the symptoms being investigated and a 25% improvement in quality of life, as assessed by a special questionnaire. The mechanism behind this exciting set of results is not clear. What is known, however, is that fibromyalgia sufferers have lower levels of the energy molecule called adenosine triphosphate (ATP) and a reduced capacity to make ATP in their muscles. It is also known from previous studies that D-ribose can fuel ATP production. This may, in part, be responsible for the effects of D-ribose supplementation which appears to reduce muscle pain and enhance quality of life for those suffering with fibromyalgia and / or chronic fatigue. D-Ribose, also known simply as ribose, is a simple sugar. Technically known as a 5 carbon monosaccharide, or pentose sugar it is used by all the cells of the body and is an essential compound in energy metabolism. Ribose also provides the structural backbone of our genetic material, DNA and RNA, certain vitamins and other important cellular compounds. If the cellular energy pool is depleted by disease, overwork, or exercise it must be replaced. Supplemental ribose can be viewed as jump-starting the energy manufacturing mechanisms and accelerating the process of energy production. To date D-ribose has been shown to be a safe supplement. Only two side effects have been noted; in very large doses, in excess of 10 grams, loose stools (diarrhoea) has been reported and in similar doses a transient dip in blood sugar levels. However, when using any supplement that contains or influences the blood sugar levels or energy levels it is always recommended that a diabetic patient consults a health professional beforehand. To reduce both of these potential but rare side effects, sensitive individuals should take D-ribose with a carbohydrate meal. Taking D-ribose at the recommended intake of between 2-5 grams per dose is not normally associated with any dose effects. A great advocate of the use of D-ribose in CFS/FM is Dr Jacob Teitelbaum. He has suggested that its critical to use the proper dose for the first 3 weeks, which is 5 grams (5000 mg) three times a day, after which the intake can be dropped to twice a day. Dr Teitelbaum is keen on using D-ribose in CFS/FM patients because he has noted that when people consume D-ribose, their body recognizes that it is different from other sugars and preserves it for the vital work of actually making the energy molecule that powers our hearts, muscles, brains, and every other tissue in the body. With its established association with the energy currency of the cell (ATP) D-ribose provides the key building block of ATP, and the presence of D-ribose in the cell stimulates the metabolic pathway our bodies use to actually make this vital compound. If the cell does not have enough D-ribose, it cannot make ATP. So, when cells and tissues become energy starved, the availability of D-ribose is critical to energy recovery. In his detailed article about D-ribose (available online) Dr Teitelbaum describes how normal, healthy heart and muscle tissue has the capacity to make all the D-ribose it needs. However, when normal tissue is stressed by overexertion, several days of rest will usually allow it to fully recover. The muscle may be sore during recovery, as we frequently see for the three or four days after a hard day of gardening or similar unaccustomed work. Eventually energy levels will be restored and the soreness will disappear. But when the muscle is chronically stressed by disease or conditions that affect tissue energy metabolism, the cells and tissues simply cannot make enough D-ribose quickly enough to recover. Heart and skeletal muscles just don’t have the metabolic machinery they need to make D-ribose very efficiently. The result is chronic, persistent pain, stiffness, soreness, and overwhelming fatigue that may never go away. Given the high level or reported muscular pain in cases of CFS/FM that fit this clinical picture it would appear reasonable to consider a trial of D-ribose following the dose recommendation outlined by Dr Teitelbaum, who as a CFS/FM sufferer himself, takes D-ribose every day. Most natural agents are needed for 4-9 months to help restore deficiencies but if D-ribose works for you its safe to use on a regular basis.

Study supports D-Ribose use

In a very recent study published in the Pain Journal this year, Dr Teitelbaum and colleagues followed 203 diagnosed CFS/FM patients over a 3-weeks course of D-Ribose therapy. They discovered that improvements began in the first week of treatment, and continued to increase at the end of the 3 weeks of treatment. Their findings are summarized below;

61.3 % increase in energy

37% increase in overall well being

29.3% improvement in sleep

30% improvement in mental clarity

15.6% decrease in pain


At the end of the study they concluded that D-ribose resulted in markedly improved energy levels, sleep, mental clarity, pain relief, and well being in patients suffering from fibromyalgia and chronic fatigue syndrome.

Further Information

The study can be view on line (Treatment of Chronic Fatigue Syndrome and Fibromyalgia with D-Ribose– An Open-label, Multicenter Study. The Open Pain Journal, 2012, 5, 32-37).

Useful product link to ProRibose.


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Miracles of mind-body medicine in chronic pain

Christine Shah, Psychotherapist at Hadley Wood Healthcare

“Tension Myoneural” Syndrome

By Christine Shah, Psychotherapist at Hadley Wood Healthcare

Everyone has experienced physical pain at one point in their lives, but for some, pain can be severe and persistent and turn into chronic pain.

Dr. John Sarno who was the director of the Rusk Institute of Rehabilitation Medicine in New York, discovered that the bulk of musculoskeletal pain was not the result of a structural damage, but in fact a tension-related pain. This condition was referred to as TMS (tension myoneural syndrome) [Sarno J. Healing back pain, New York: Warner Books, 1991]

John Sarno’s theory states that the autonomic nervous system is responsible for the great majority of chronic pain conditions, and that the underlying cause of that pain is the minds defence mechanism against unconscious mental stress which is distracted by  physical pain and therefore conscious awareness is prevented. In other words the physical pain becomes obvious to the patient and emotional pain becomes invisible.

The autonomic nervous system controls the circulation of the blood flow in the body. When there is not enough blood flow to a particular tissue, oxygen is reduced and the result will be symptoms, such as pain, numbness, tingling weakness etc. These symptoms can occur in the neck, knee and other parts of the body.

David Schlechter states that the symptoms have a tendency to move to other parts of the body and considers symptom movement to be an important indicator that the pain is from TMS.

Schlechter and Sarno consider a prior history of other psychosomatic disorders such as irritable bowel syndrome and tension headache as examples of TMS pain. However a physical examination tests and imaging studies may be needed to rule out serious conditions, such as tumours.

Psychological Therapy for TMS patient

The Psychiatrist Henry Maudsley [1918] wrote:  ‘The sorrow which has no vent in tears may make other organs weep’.

He states: When our habitual ways of coping psychologically are overwhelmed, we are capable of somatising psychological pain. In such cases, the mind senses that the emotions are too painful to experience, so it attempts to protect the psyche. That is to say that experiencing the pain physically, as, terrible as it may feel, is more tolerable than feeling the depth of the psychological pain.

Studies have revealed that TMS clients avoid a variety of feeling, such as anger, sadness, helplessness, dependency, envy, guilt, even happiness. Sarno and the psychologists he worked with found that when TMS clients were focused on their physical pain, they were less apt to focus on deeper psychological pain.

Most people have experienced a way of distracting themselves from difficult emotions.

To relieve anxiety or depression, people overeat, smoke, drink alcohol, use drugs etc.  All these activities serve to shift a person’s focus from their emotional pain to a different sensation. Physical pain is simply the minds way of shifting the focus for us.

Examples of repressed emotions could be:

A   certain childhood experiences, such as abuse or lack of love,

B   personality traits such as perfectionism conscientiousness and a strong need to be liked by everyone,

C   current life pressures

D   aging and mortality and

E   situations in which the patient experiences conscious but unexpressed anger

TMS treatment is gaining momentum, and author and physician, Dr. Marc Sopher, speaks for many when he writes: ‘Ultimately, I am confident that TMS theory will become part of mainstream medicine for the simple reason that it is correct, and more successful at alleviating pain than any other modality.

Once TMS has been clinically diagnosed, the client’s acceptance of the diagnosis is an integral part of recovery.

One of the primary goals of TMS treatment is to help clients reframe the meaning of their pain. Instead of focusing on it with frustration, fear and powerlessness, the client learns to use the pain as a guide to become aware of his emotions.

An essential part of counselling is to help the clients to identify these emotions, and eventually accept and express these painful parts of themselves [E Sherman, personal communication, 09/05/09].

If you feel that you have exhausted every other means of treatment perhaps psychological counselling is your answer?

(Parts taken from a BACP article [Therapy Today] published in April 2010, p16 to 21)


National Institute of Health NIH guide:new directions in pain research I. September 1998

Sarno J. Healing back pain.New York, Warner Books,1991

Sarno J. The mindbody prescription: healing the body, healing the pain New York, Warner books, 1998

Sarno J. The divided mind: the epidemic of mindbody disorders , New York, Harper Collins, 2006

Read the interview with Dr Sarno

An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind

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Fibromyalgia lecture – Crosshouse Hospital, Ayr.

This years proposed topic for a lecture I am giving at Crosshouse Hospital’s Pain Study day is on the management of “Fibromyalgia” – a real can of worms! Crosshouse hospital hosts an annual Pain Study Day to which various consultants from anesthesia, neurology and pain management attend along with key nursing and physiotherapy staff with a keen interest in the management of chronic pain syndromes. The various topics to be discussed on the September 4th Study Day have not yet been finalised but I propose to publish my presentation and notes for anyone who is interested. The study day is a closed seminar and only open to Crosshouse Hospital staff. Below is a copy of my last informal lecture introducing the concepts of osteopathy and acupuncture.
Cross House Hospital Lecture 2007

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Vitamin D and chronic pain

Its an ongoing issue; getting enough vitamin D but not getting excessive exposure to the damaging effects of UV rays from the sun. It is now becoming well acecpted that low levels of vitamin D appear to be associated persistent pain syndromes and impaired functioning of the neuro-muscular system. There is growing interest in the observation by specialists dealing with musculoskeletal pain that those suffering or previously diagnosed or labelled with fibromyalgia are actually suffering from a vitamin D deficiency. This may affect those with darker skins or people who do not get much sun light exposure.
The key issue of interest in the study (published in the journal Pain Medicine) showed that those with low levels of vitamin D needed nearly twice as much pain medication compared to those with normal levels.
Vitamin D is a safe supplement for most people. Those suffering from chronic pain syndromes or fibromyalgia should consider using it for a good 3 months and especially during the dark winter months. However, supplements of vitamin D should be avoided by those with kidney failure or stones, primary hyperparathyroidism or sarcoidosis.
Similar findings have been reported in the New Zealand Medical Journal. For those interested in the effects of vitamin D on bone health click here for a previous blog entry on the subject.

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