At one time, nearly all prescriptions were compounded. With the advent of mass drug manufacturing in the 1950s and ’60s compounding rapidly declined. The pharmacist’s role as a preparer of medications quickly changed to that of a dispenser of manufactured dosage forms, and most pharmacists no longer were trained to compound medications. However, the “one-size-fits-all” nature of many mass-produced medications meant that some patients’ needs were not being met.

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What Are Diabetic Foot Problems?

Foot problems are a leading cause of hospitalization for the eight million persons in the United States who have been identified as having diabetes mellitus. Expenditures related to diabetic foot problems total hundreds of millions of dollars annually. It is estimated that 15% of all diabetics will develop a serious foot condition at some time in their lives. Common problems include infection, ulceration, or gangrene that may lead, in severe cases, to amputation of a toe, foot or leg. Most of these problems are preventable through proper care and regular visits to your podiatric surgeon. This physician can provide information on foot inspection and care, proper footwear, and early recognition and treatment of foot conditions.

Causes

Foot problems in persons with diabetes are usually the result of three primary factors: neuropathy, poor circulation, and decreased resistance to infection. Also, foot deformities and trauma play major roles in causing ulcerations and infections in the presence of neuropathy or poor circulation. Neuropathy (Nerve Damage) Your ability to detect sensations or vibration may be diminished. Neuropathy allows injuries to remain unnoticed and untreated for lengthy periods of time. It may cause burning or sharp pains in feet and interfere with your sleep. Ironically, painful neuropathy may occur in combination with a loss of sensation. Neuropathy can also affect the nerves that supply the muscles in your feet and legs. This ‘motor neuropathy’ can cause muscle weakness or loss of tone in the thighs, legs, and feet, and the development of hammertoes, bunions, and other foot deformities.

Poor Circulation

Persons with diabetes often have circulation disorders (peripheral vascular disease) that can cause cramping in the calf or buttocks when walking. The symptoms can progress to severe cramping or pain at rest, with associated color and temperature changes (the feet may turn bright red when hanging down and constantly feel cold). Also, the skin may become shiny, thinned and easily damaged. A reduction in hair growth and a thickening of the toenails might also be present. Poor circulation, resulting in reduced blood flow to the feet, restricts delivery of oxygen and nutrients that are required for normal maintenance and repair. Healing of foot injuries, infection or ulceration is affected. Peripheral vascular bypass operations may avert lower extremity amputation.

Infection

Persons with diabetes are generally more prone to infections than non-diabetic people. Due to deficiencies in the ability of white blood cells to defend against invading bacteria, diabetics have more difficulty in dealing with and mounting an immune response to the infection. Infections often worsen and may go undetected, especially in the presence of diabetic neuropathy or vascular disease. Often, the only sign of a developing infection is unexplained high blood sugar, even without fever. The combination of fever and high blood sugar often warns of a severe infection requiring hospitalization. Lesser degrees of infection are often treated on an outpatient basis.

Foot Deformities

Foot deformities such as hammertoes, bunions, and metatarsal disorders have special significance in the diabetic population. Neuropathy places the foot at increased risk for developing corns, calluses, blisters and ulcerations. If these are left untreated, serious infections may result.

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Special deformities can occur in persons with neuropathy and very good circulation. A Charcot joint, resulting from trauma to the insensitive foot, causes the foot to collapse and widen. This destructive condition is often first heralded by persistent swelling and redness, mild to moderate aching, and an inability to fit into your usual shoes.

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If this occurs, it is important to stay off the foot and see your podiatric surgeon immediately.

Ulcers of the Foot

An ulceration or ulcer is usually a painless sore at the bottom of the foot or top of the toes, resulting from excessive pressure at that site. Ulcers frequently underlie a pre-existing corn or callus that was allowed to build up too thickly. Trauma from heat, cold, shoe pressure, or penetration by a sharp object are also potential causes. Neuropathy allows the lesions to develop because the normal warning sense of pain has been lost and they go unrecognized. Continued pressure or walking on the injured skin creates even further damage and the ulcer will worsen. The open sore will frequently become infected and may even penetrate to bone. Treatment relies on early recognition of the ulceration by a podiatric surgeon, avoidance of weight bearing activities such as walking, avoidance of wearing “closed-in” shoes, and early intervention.

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Besides local wound care, dressings and antibiotics, other measures may be necessary to adequately relieve pressure on the area. When use of crutches, a wheelchair, or rest is not feasible, plaster casts, braces, healing sandals, or orthoses (special shoe inserts) can be used to protect the foot while it heals. If circulation is inadequate to allow healing, your podiatric surgeon may refer you to a vascular surgeon for appropriate evaluation and possible vascular reconstructive surgery. Once an ulcer has healed, it is important to continue to see your podiatric surgeon regularly. Special footwear and inserts may be recommended to protect your feet and prevent new or recurrent lesions from developing.

Foot Surgery in the Diabetic Patient

Realizing the potential danger of foot deformities in the diabetic patient, corrective foot surgery is an option when you are in generally good health and have good circulation. Most deformities progressively worsen over time as do the effects of neuropathy and vascular or circulatory disease. When foot deformities cannot be managed effectively with conservative care, surgery may be indicated. Podiatric surgery is often “same day” surgery under local anesthesia to minimize potential complications. In some cases, such as in the presence of an active ulceration, hospitalization may be necessary to properly monitor your postoperative progress. Surgery may also be required to heal an ulceration or to eradicate some infections, especially those involving the bone. Your cooperation is an important part of your care. You must guard against injury and provide the daily care necessary to maintain the health of your feet.

Footwear Guides

Shoes must always fit comfortably and have adequate width and depth for the toes. Leather shoes easily adapt to the shape of your feet and allow them to “breathe.” Athletic shoes, jogging shoes and sneakers are usually excellent choices if they are well fitted and provide adequate cushioning. Your podiatric surgeon may recommend “extra depth” shoes, custom molded shoes to adapt to your particular needs, or orthoses to provide cushioning and support. Always check your shoes for foreign objects or torn linings before putting them on. You should wear two or three pairs of shoes each day so that one pair is not worn for more than four to six hours. New shoes should be worn for only a few hours at a time, and you should take care to inspect your feet for any points of irritation. Socks should be well fitted without seams or folds. They should not be so tight as to interfere with circulation. Well-padded socks can be very protective if there is an abundance of room in your shoes. Avoid wearing open-toed shoes or sandals until you have discussed this with your podiatric surgeon. Above all else, do not walk with bare feet.

Foot Care Guidelines

• Inspect your feet daily for blisters, bleeding, and lesions between your toes.
• Use a mirror to see the bottom of your foot and heel.
• Do not soak your feet unless the temperature of the water is lukewarm, not as hot as you can stand it (95°-100° Fahrenheit).
• Avoid temperature extremes – do not use hot water bottles or heating pads on your feet.
• Wash your feet daily with warm, soapy water and dry them well, especially between the toes.
• Use a moisturizing cream or lotion daily, but avoid getting it between the toes.
• Do not use acids or chemical corn removers.
• Do not perform “bathroom surgery” on corns, calluses, or ingrown toenails.
• Trim your toenails carefully and file them gently. Have a podiatrist treat you regularly if you cannot trim them yourself without difficulty.
• Contact your podiatric surgeon immediately if your foot becomes swollen or is painful, or if redness occurs.
• Do not smoke.
• Learn all you can about diabetes and how it can affect your feet.
• Have regular foot examinations by your podiatric surgeon.

Back to Article Index While these are some of the most commonly prescribed treatments for diabetic foot problems, others may be used. The podiatric surgeon will determine which treatment is likely to be the most successful in each case. © 1994-2009 The American College of Foot and Ankle Surgeons

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Your Feet

Your feet are very complex structures, each composed of a network of 26 bones, 29 joints, and many muscles that support your body weight. They are capable of bearing great loads over many miles. In fact, people take an average of several thousand steps every day. When functioning properly, your feet handle all of the demands you place upon them without discomfort. When discomfort occurs, rapid treatment usually results in complete healing and a return to full function. In this brochure, many common foot ailments are discussed and initial remedies are suggested.

Common Foot and Ankle Problems

Ingrown Toenail — Results in redness, swelling, soreness and possible infection; often painful Recommendation: Soak the foot in warm water and remove the ingrown part of the nail. If pain or redness persists, contact a podiatric surgeon.

Corns & Calluses — Frequently caused by ill-fitting shoes, poor quality shoes, or various foot deformities. Recommendation: Purchase well constructed shoes that fit properly, allowing ample space between the toe and the end of the shoe to prevent irritation.

Hammer Toe — An abnormal contraction of one or more toes which often causes them to rub on the top of the shoe. Recommendation: Obtain shoes of larger size with roomier “toe boxes” to decrease pressure on the toes. Consult a podiatric surgeon for possible surgical straightening of one or more hammer toes if careful shoe selection does not relieve the discomfort.

Warts — Circular growths, usually found on the toes or the bottoms of the feet, that are caused by viruses.

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Recommendation: Warts should be professionally examined and treated by a podiatric surgeon as they may enlarge in size and multiply due to their viral nature.

Bunion — An enlargement of the bone on the inside of the foot at the big toe. Recommendation: Obtain shoes of greater length and width to provide space for the bunion. Avoid pointed toe shoes. Wear shoes of softer material to decrease irritation. If the pain persists, a podiatric surgeon may prescribe orthoses (special shoe inserts) or recommend treatment alternatives, including surgical correction.

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Flat Feet — Caused by a lack of internal support for the arch of the foot, often resulting in fatigue and pain when standing and walking. Recommendation: Obtain well-cushioned shoes with good arch support. Consult a podiatric surgeon if discomfort or fatigue persists.

Heel Pain (Plantar Fasciitis) — An irritation of the ligament running along the bottom of the foot and attaching to the heel, commonly causing pain upon arising in the morning or following increased activity. Recommendation: Wear cushioned shoes with a slightly elevated heel (about 1″ – 11/2″). Insert an arch support to decrease pressure on the heel. If discomfort persists, consult a podiatric surgeon who may recommend custom orthoses, professional treatment, or surgical correction if conservative care fails to resolve discomfort.

Ankle Sprain — Condition that results from an inherently unstable ankle, trauma, or as a result of an athletic injury. Recommendation: Rest, ice, compression and elevation (RICE). See a podiatric surgeon immediately to rule out a fracture or a ligament tear. Immediate treatment often results in complete healing and a return to normal functioning.

Recommendations for Healthy Feet

• Wear properly fitted shoes.
• Wear shoes made of leather or canvas.
• Wash your feet daily.
• Wear cotton socks.
• Trim your toenails straight across.
• Inspect your feet daily to guard against unusual growths, cuts, non-healing sores, etc.

Foot Health Checklist

• My heel hurts, especially after I have been lying down.
• My toenail has become thickened and discolored.
• I have growths on my foot that look like calluses with black dots in the center.
• My ingrown toenail has become red, swollen and painful.
• My toes are overlapped and bent.
• I have diabetes.
• My toe joints are stiff, enlarged and painful.
• My ankles are unstable and often “give way.”
• My toes are misshapen and have growths.
• My toes feel numb or burn.
• I have pain in the ball of my foot.

These are just a few of the warning signs of common foot and ankle problems. If you have checked any of the above, consult a podiatric surgeon who is a member of the American College of Foot and Ankle Surgeons.

Your Feet Should Not Hurt

Many common foot and ankle problems may be alleviated by simple home remedies. Should a problem worsen, cause intense pain, or last for more than a few days, consult a podiatric surgeon who is a member of the American College of Foot and Ankle Surgeons. Individuals with medical conditions such as diabetes should receive regular examinations by a podiatric surgeon to ensure proper foot health. Back to Article Index © 1994-2009 The American College of Foot and Ankle Surgeons

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What to Do about a Bunion?

In the front of the foot, the joint at the base of the great toe is the most complex. Here the bones, tendons and ligaments work together to transmit and distribute the body’s weight, especially during movement. Should this joint become abnormally stressed over an extended period of time, a bunion deformity may result. A bunion (from the Latin “bunio,” meaning enlargement) is a protuberance of bone or tissue around the joint. The enlargement occurs either at the base of the great toe or on the outside of the foot, at the base of the little toe where it is called a “bunionette” or “tailor’s bunion.” Bunions at the base of the great toe usually begin when the big toe starts moving toward the smaller toes when tight, pointed shoes are worn. This crowding puts pressure on the joint, pushing it outward. The movement of the joint in this outward direction starts the formation of a bunion. A common deformity of the big toe joint, a bunion occurs mostly among people who wear shoes. Women are more frequently affected with bunions because of tight, pointed, confining or high-heeled shoes. Wearing high heels is especially stressful on the joints of the foot because all of the body’s weight rests there. The foot is then forced into a narrow, pointed “toe box”, compounding the problem. Older people are also vulnerable to bunions because of the higher incidence of arthritis affecting the big toe joint.

What Causes a Bunion?

A bunion is most often a symptom of faulty mechanics of the foot. The deformity runs in families, but it is the foot type that is hereditary, not the bunion. People with flat feet or low arches are more prone to develop the problem than those with higher arches. Bunions also may be associated with various forms of arthritis. Arthritis can cause the joint’s protective covering of cartilage to deteriorate, leaving the joint damaged and with a decreased range of motion. Parents who have bunions should know that there is a strong hereditary predisposition to bunion development, and should have children evaluated if early signs of deformity and/or discomfort are evident. If the child has the same foot type, there is a possibility that a bunion will eventually develop.

Symptoms

Pain from a bunion can be mild, moderate or severe, making it difficult to walk in normal shoes, especially high-heeled shoes. The skin and deeper tissues around the bunion also may be swollen or inflamed. The other toes can be affected by a bunion, as a result of pressure from the great toe pushing inward toward the lesser toes. Toenails may begin to grow into the sides of the nail bed; the smaller toes can develop corns and become bent (hammertoes); or calluses may form on the bottom of the foot.

Treatments

Treatments vary depending on the severity of pain and deformity. Left untreated, bunions tend to get larger and usually more painful. Evaluation by a podiatric surgeon should be sought at the first sign of pain or discomfort, so that severe deformity can be avoided.

Early Treatment

The main goal of early treatment is to relieve pressure on the bunion and smaller toes, and to diminish the progression of joint deformities. Padding the bunion is an important first step, as is wearing shoes that are large enough to comfortably accommodate the bunion (such as sandals, athletic shoes or shoes made from soft leather). Stiff leather shoes may be stretched slightly for greater comfort. Tight, confining or high-heeled shoes should be avoided. Medications, such as nonsteroidal anti-inflammatory drugs or cortisone injections, may be prescribed to ease pain and inflammation caused by joint deformities. Physical therapy, ultrasound treatment, whirlpool baths or other techniques can also provide temporary relief. Orthoses (shoe inserts) may be useful in controlling abnormal foot movement, and may reduce symptoms for those with a painful bunion that has not yet caused a significant bony abnormality at the joint. If a systemic disease like rheumatoid arthritis or gouty arthritis is related to the bunion, appropriate medical treatment may be recommended.

Surgical Treatment

When conservative treatment does not provide satisfactory relief from symptoms, or when the condition interferes with your activities, surgery may be necessary. Pain and deformity are significantly reduced in the great majority of patients who undergo bunion surgery. In addition to easing pain, the purpose of bunion surgery is to remove the enlargement and realign the joint to restore normal function. This means that after surgery, the foot can carry the body’s weight properly, and that special shoes are no longer needed. Postoperative orthoses or supportive devices may be recommended to improve foot function. Surgery may be performed at a hospital, surgical center or properly equipped office operating room. Depending on the procedure, the facility at which it is performed and the patient’s medical status, the surgeon may choose a local, spinal or general anesthetic. In many cases, the procedure can be performed under local anesthesia.

Types of Surgery

Many surgical procedures are used to correct bunions. The decision to employ a prodedure is based on the severity of the deformity, the patient’s age, the general health of the patient, their activity level, and the general health of the bones and connective tissue. Other factors may influence the choice of a procedure used. The general guidelines for types of surgery are: Mild Bunion, Moderate Bunion, Severe Bunion, and Arthritic Bunion or big toe joint. For a mild bunion, the podiatric surgeon may remove the enlarged portion of bone and realign the muscles, tendons and ligaments surrounding the joint. For a moderate bunion, the podiatric surgeon may cut the bone and shift it to its proper position. Whether or not the bone is cut depends on the severity and location of the deformity. In addition, the surrounding tendons and ligaments may need to be repositioned. For a severe bunion, a combination of the following procedures may be necessary: removal of the enlarged portion of the bone; cutting and realignment of the bone; and correction of the tendons and ligaments.If the joint is destroyed beyond repair (commonly seen in arthritis), it may need to be reconstructed or replaced with an artificial joint. Joint replacement implants may be used in the reconstruction of the big toe joint.

Post-Operative Care

Following surgery to correct a mild or moderate bunion, the foot is bandaged and a postoperative shoe is usually worn for three to four weeks. The amount of activity allowed will vary, and the podiatric surgeon may suggest that flexible footwear be worn for several weeks either directly after surgery or after wearing a postoperative shoe. If the bone was cut, as in surgery for a moderate to severe bunion, it may be held in place with an internal pin, screw or absorbable rod. In many cases, a slipper or short leg cast is worn for four to six weeks, and walking is assisted by crutches. Movement of the toe joint is important after any type of bunion surgery. Specific instructions for exercising the joint will be provided by the podiatric surgeon. After the foot has healed, and if the bunion was the result of improper foot function or foot type, the cause of the problem should be addressed. Orthoses may be prescribed to protect the foot and improve its function. Guidelines may also be provided by the podiatric surgeon on the types of shoes that should be worn. These instructions should be followed carefully to avoid recurrence of the bunion.

What Should I Expect After Surgery

After surgery, the foot may become narrower. Also, for a period of time, the joint may remain slightly stiff and not be as flexible as before the surgery. Gradual return to normal activity will be recommended by the podiatric surgeon as healing progresses.

Risks

Some risks when considering bunion surgery include joint stiffness, malalignment, joint pain and recurrence. The ultimate goal is to relieve pain and prevent the bunion from recurring. Back to Article Index © 1994-2009 The American College of Foot and Ankle Surgeons

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Arthritic Disorder and Treatments

Joint stiffness, pain or tenderness, swelling and/or redness that persists for more than two weeks-all may signal arthritis. Any of 100 forms of arthritis can damage our bodies, especially the joints, gradually wearing away protective cartilage where the bones meet to make a joint. The force our body weight generates on the toe and ankle joints makes them particularly susceptible to arthritis. As cartilage erodes and bone rubs against bone, the joint becomes painful. Movement may become limited as bone ends erode or thicken, sometimes developing painful outgrowths, or spurs. If left untreated, damage to cartilage can seriously weaken the joints, often leading to pain and deformities.

About Arthritis

Rheumatoid arthritis and osteoarthritis are two common forms of arthritis that affect millions of Americans, especially those over age 45. The cause of rheumatoid arthritis, a ‘systemic’ disease that can affect the entire body, is unclear. It is believed to result when the body produces enzymes that inflame the joints and other tissues. Osteoarthritis, sometimes called degenerative arthritis, or referred to as joint “wear and tear,” is isolated to the joints. Pain and stiffness caused by cartilage destruction develop slowly as a result of years of everyday living.

Surgery When Joint Problems are Severe

Surgery to reconstruct the joint may be needed if arthritis causes chronic problems that cannot be controlled by medications, orthotics or physical therapy, especially if: pain is constant toe motion is limited, causing a change in natural stance or walk deformities (such as bunions and hammertoes) restrict normal activities In the vast majority of cases, reconstructive surgery can bring improvement. Pain relief is a common benefit. Other benefits may include an improved ability to move the joint, or an improved appearance. Goals of surgery are different for each individual, and should be discussed with the podiatric surgeon. While surgical care will not cure arthritis or completely restore the joint to its natural health, it will ease pain and make daily activities more manageable.

Surgical Treatments

If bone on both sides of the joint is damaged, the podiatric surgeon may remove a small portion of cartilage and bone, then reconstruct the synovium, ligaments and tendons. This is called a resection. Fusion or arthrodesis relieves pain by uniting the bones of the joint into a permanent, yet useful position, preventing any motion at the site. The joint may require a complete reconstruction or resection arthroplasty. Here, the podiatric surgeon removes the bone ends at the joint, corrects tendons and ligaments that may have stretched as a result of arthritis, and replaces the joint with an implant (prosthetic joint). Two of these surgeries, fusion and implant reconstruction, are described in greater detail in “About Your Foot Surgery.”

Implants and Foot Surgery

The choice to use an implant is made carefully, only after the podiatric surgeon has decided that another type of surgery would not provide as many benefits. Implants made from silicone rubber, polyethylene (a form of plastic), or titanium (see “implant Types and Materials”) are quite safe. Like other artificial body parts, implants used in the foot have been evaluated by the Food and Drug Administration (FDA).

Implants for Pain Relief and Support

The narrow space separating the two bones of the joint permits movement. An implant’s primary purpose is to maintain this joint space and support the toe. Because the implant replaces damaged or diseased bone and the bone’s cartilage, it keeps the toe at an appropriate length. Without an implant, the toe may appear shorter. The implant helps eliminate pain, and provides stability to the previously weakened joint. A secondary purpose of an implant is to permit the toe to bend and function more freely. As the joint heals, new tissue forms around the implant, making the joint stable and the reconstruction more durable.

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About Your Foot Surgery

Surgery usually requires only one to two hours. It is often completed on an outpatient basis, but a short hospital stay of one or two days is not unusual.

Implant Reconstruction

The podiatric surgeon will expose the damaged joint and carefully remove any inflamed tissue. A small portion of damaged bone also will be removed, and the bone ends smoothed. The next step is enlargement of the natural canals within the bones. The sterilized implant (double-or single-stem) is then inserted and is supported by the bones. Finally, the tendons, ligaments and joint capsule are reconstructed around the implant. Antibiotics may be administered both before and after surgery.

Fusion

A small portion of the bone ends at the joint are removed. The bones are then compressed together, so that the two bones unite. In some cases, a bone graft may be necessary. The fused joint will be held in position with a stainless steel or dissolvable pin, or small bone screws and plates, to allow for healing.

Care After Surgery

Immediately after surgery, the entire foot will be carefully wrapped in a bulky dressing or cast as protection for the first few days. Keeping the foot elevated during this time will help minimize swelling. Some swelling and stiffness can be expected following surgery, for as long as eight to twelve weeks. Crutches may be needed for walking or standing as the foot heals.

Special Shoes and Splints

After surgery, the foot will be placed in a special shoe that relieves pressure from the ball of the foot and keeps the toe aligned as it heals. A splint may be worn for the first few weeks after surgery, and possibly for an additional three to six weeks.

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Although each person is different, it is likely that most activities can be resumed within three months after surgery. The podiatric surgeon will provide specific instructions as healing progresses.

Activity Restrictions

The podiatric surgeon may restrict any activity for at least 24 hours. Depending on which joint was fused, a cast and crutches may be necessary for as long as six weeks.

Implant Types and Materials

Most implants used in the foot are made from silicone rubber, a synthetic compound that is both flexible and strong. When a less flexible implant is needed, podiatric surgeons choose implants made from metals such as titanium, a durable, lightweight material. Some implants combine a metal with a plastic such as polyethylene. All implant designs and materials are carefully evaluated and tested by the FDA. Double-stemmed implants replace damaged bone at the base joint of any of the toes. They are widely used when cartilage is lost, the toe is painful, and to treat deformities such as bunions or bone spurs. Stems on either side of the midsection support the implant within the bones. Hammertoe implants, used to correct painful hammertoe deformities, also have two stems that fit into either the base or middle joints of the toe. Implants with a single stem, made from either silicone rubber or titanium, may be used in the base joint of the big toe to treat a bunion, bone spur or toe stiffness and pain. This implant is most effective when only one side of the joint is damaged. Two-piece ankle implants made of metal and plastic are used in less active individuals with severe arthritis, most often rheumatoid disease. The implant replaces the natural bones of the joint, permitting the ankle to retain a limited amount of movement.

Answers to Questions About Implant Reconstruction

How Long Will the Implant Last? Although every individual is different, most implant recipients can expect the benefits of surgery to last for at least 10 to 20 years. Several thousand people have had these implants for more than 15 years, and remain pain-free and without complications. Implants are designed specifically for durability and the ability to withstand the pressures of joint movement. No implant, however, is indestructible. With use, especially in young or active people, it is possible that the implant will wear down. Another surgery may become necessary. Your podiatric surgeon can advise you about other patients’ experiences with implant durability. While these are some of the most common treatments for arthritic disorders, others may be used. Your podiatric surgeon will determine which treatment is likely to be most successful in each case. Back to Article Index © 1994-2009 The American College of Foot and Ankle Surgeons

Fibromyalgia Links

• Full Program Description
• Our Fibromyalgia Book
• “FMS: Definitions & Solutions” in the LA Psychologist
• National Library of Medicine’s FMS
• The New 2010 FMS Diagnostic Criteria
• Medication Issues and Behavioral Treatment
• Interview in the ACPA Chronicle

What Causes Fibromyalgia Syndrome (FMS)?

We do not know. However, research over the last twenty-five years indicates that the problem starts with an imbalance in the neurotransmitters in the brain that control your sensitivity to pain, sleep, and muscle metabolism, including the muscles that control your gut and blood vessels. The current belief among all leading researchers in this field is that an imbalance in neurochemicals in the central nervous system (brain and spinal cord), especially serotonin and Substance P, results in a variety of mental and biologic abnormalities, which explains the signs and symptoms of fibromyalgia syndrome. This process is now called central or sensory sensitization. It results in the person perceiving normal sensations, such as light touch or normal stretching, as painful. Most people with fibromyalgia syndrome report that their mood is irritable; when this occurs their whole nervous system is irritable: muscle, gut, bladder, skin and sensitivity to the environment. Hypersensitivity and irritability are the same thing.

Functional Definition of Fibromyalgia Syndrome

FMS results from hypersensitivity throughout the entire body associated with a non-restorative sleep disorder or insomnia. The characteristic symptoms may include: pain, tenderness, fatigue, anxiety, depression, diminished focus and memory, headaches, and altered function of the stomach, bowel, skin, nerves, muscles, tendons, sinuses, heart and eyes.

Disease or Syndrome?

It is not a disease; it is a syndrome (a pattern of symptoms). It is an imbalance of the nervous system chemistry, which can be re-balanced. You can have it for twenty years, but still rebalance and normalize your chemistry. There is no degeneration or inflammation with FMS. If you are familiar with fibromyalgia, you know that many doctors, authors and web sites refer to fibromyalgia syndrome as chronic and incurable. It does appear to be so, when the only treatment is medication. However, as most medications cause adverse effects (e.g. fatigue, insomnia, nausea, and headaches) they keep the body out of balance. (See Medication Issues and Behavioral Treatment for more info) Solutions for Wellness, in contrast, has developed a program for rebalancing the nervous system. For thirty-two years, we have been helping people with fibromyalgia syndrome recover without medication by helping them regain restorative sleep naturally, exercise safely, use food to increase energy and mental sharpness, and learn how to cope more effectively with pain and stress.

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The key to getting well with fibromyalgia syndrome is fully correcting the sleep disorder without medications. The goal is to be calm and sleepy before bed, to wake fully and mentally rested 5 out of 7 mornings and to have peak energy in the morning.

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When a person can maintain this routine for three months, they become physiologically hardy and symptoms of FMS start disappearing. Interestingly, widespread pain resolves before tenderness leaves. Some people with FMS believe they do not have a sleep disorder because they fall asleep easily and sleep through the night. They wake up very tired and believe the fatigue is from the fibromyalgia. This person actually has a non-restorative sleep disorder. They are not sleeping deep enough and this is promoting their FMS. This type of sleep disorder can be corrected through behavioral sleep retraining. Our experience leads us to a very clear conclusion: people can recover from fibromyalgia syndrome in the same way that people can recover from serious depression or any other chemical imbalances. Because FMS does not degenerate or inflame muscles, or directly affect the immune system, it is not a form of arthritis in the muscles, nor is it an autoimmune disorder. The only reason that it gets connected with these diseases/disorders is because of common symptoms such as pain or tenderness in muscles or tendons around the joints.

Who Gets Fibromyalgia Syndrome?

• Fibromyalgia syndrome affects 2% or more of people (adults and children) in the United States. It can affect 10% of specific high-risk populations, such as women between twenty-five and sixty years of age.
• It is the second most common rheumatic disorder after osteoarthritis, and it is twice as common as rheumatoid arthritis.
• It affects women more than men, approximately six to one, though the cause is not known.
• It primarily affects people between the ages of twenty-five and sixty, but it can occur in all populations.
• For some people there is a genetic predisposition.

How is it Diagnosed?

In 1990 the American College of Rheumatology(ACR) identified the criteria for selecting participants for fibromyalgia research studies. These became the American College of Rheumatology Fibromyalgia Syndrome Classification Criteria. They required eleven of eighteen tender points to be tender to light touch. The criteria was not designed to be a diagnostic criteria, but doctors started using it as such because nothing else existed. There has been a lot of controversy about this. In the past, many doctors believed that the number of tender points (See the important terms section for a definition) can vary from zero to eighteen in patients with classic fibromyalgia syndrome. As a result, many doctors refused to make the diagnosis unless the person had eleven out of eighteen tender points. Consequently this resulted in patients being denied disability insurance and treatment in the worker’s compensation system. In 2010 the ACR published new diagnostic criteria. These criteria eliminated the requirement for positive tender points. The tender points are not part of fibromyalgia. They exist in everyone’s body and are tender under strong pressure. The difference is that in fibromyalgia patients the points can be tender under light pressure. They are a barometer of how sensitive a person is. Tender points are never treated. Trigger points are completely different. They are abnormal and can be treated. A person with eighteen out of eighteen tender points and no widespread pain does not have fibromyalgia; they have sensitive tender points. The new criteria also emphasizes the importance of restorative sleep and cognitive impairment in the diagnosis of fibromyalgia.

The New American College of Rheumatology FMS Diagnostic Criteria 2010

1. Fatigue, waking un-refreshed, and difficulty thinking (cognitive fog).
2. Widespread pain index (WPI) between three to six body regions from a specific list.
3. Symptom severity (SS) scale score equal or greater than nine. (This is the sum of the severity of the top three core symptoms plus the score from a symptom list.)
4. Symptoms have been present for more than three months.
5. The patient does not have another disorder that would explain the pain.

Go here for the full criteria.

Oral medications must pass through the digestive system and bloodstream to reach the affected area. Relief can take anywhere from several minutes to a few hours. Our topical creams are applied directly to the affected area providing instantaneous relief.