Fibromyalgia: Symptoms, Causes and Natural Support Strategies

Fibromyalgia: Symptoms, Causes and Natural Support Strategies

Fibromyalgia is a condition characterized by chronic pain and fatigue.  3-5% of the population suffers from this condition with over 80% being women.  This is one of the fastest growing disabling conditions in the US.   There are not any specific lab tests or definitive markers for the diagnosis.  Instead, it relies on a bevy of symptoms and tender points along the body.  This article discusses fibromyalgia symptoms, root cause factors, and natural support strategies.

Fibromyalgia is classically diagnosed with the positive reaction to 11 of 18 specific tender point sites on the body.  Other classic findings include chronic fatigue, sleep challenges, normal blood tests, and a history of widespread pain particularly in the neck and back (1).

What Causes Fibromyalgia:

The medical community hasn’t come up with a true defining mechanism of action for fibromyalgia.  Many have described it as a “central sensitization syndrome” caused by biological abnormalities in the nervous system which act to produce pain and cognitive impairments as well as psychological problems (2).

The term “fibro” means “fibrous tissue” in Latin and “myo” means muscle in Greek with “algia” meaning pain syndrome.  So, the name implies a painful condition of the muscles and connective tissue.  Individuals with fibromyalgia deal with a number of physical and psychological issues including the following:

The Process of Central Sensitization:

Most scientists believe this is a chronic nervous system sensitization condition of the muscle fascia.  This means that the individual has a heightened sense of pain and tenderness despite the fact that inflammatory agents are not consistently present (3, 4).

When you prick your finger, there is a whole host of sensory information that is processed through the tissue cells, spinal cord, and brain in order for you to perceive pain.  We all have a certain threshold response that must be overcome for us to perceive a painful response.  Individuals with fibromyalgia have a very low pain threshold to where very little, if any, stimulus is needed to provoke a painful response.

HPA Axis Abnormalities:

One of the major factors associated with fibromyalgia is dysregulation in the Hypothalamic-Pituitary-Adrenal Axis (HPA).  This is a problem that occurs when someone has a heightened and ongoing fight or flight stress response.  When you are stressed, your HPA axis naturally increases its activity.  When this is prolonged, it can create long-term issues as these areas fatigue and fail.

Chronic pituitary and adrenal fatigue reduces sex hormone (estrogen, progesterone, and testosterone) production and human growth hormone (HGH) production.  These hormones are critical for the healing process of the body.  Research has shown this is a characteristic trait in individuals suffering from fibromyalgia (5, 6)

Poor Healing Response:

Individuals with fibromyalgia typically have some sort of a triggering event such as a physical, chemical or psychological trauma.  This could be a car accident or fall, a major infection or exposure to a toxic chemical agent or the loss of a loved one, child abuse, spousal abuse, etc.

This trauma drives up the HPA axis as it normally should.  The problem occurs when these individuals are unable to heal and adapt properly.  Most people are able to sleep, heal, and adapt to the trauma they experience in life.  After a few weeks, they are much better.

Fibromyalgia occurs when the individual is unable to sleep and heal effectively.  The poor healing response leads to increased pain sensations and that only drives up the HPA axis even more creating a vicious cycle where the stress response blocks healing and promotes further stress, pain, and poor healing (7).

The Microbiome and Fibromyalgia:

There has been a tremendous amount of research linking the gut microbiome and neurological health.  Research has indicated that low levels of healthy lactobacillus and Bifidobacterium are linked with increased brain and nervous system excitability and neurological inflammation (8, 9).

The research shows that 30-70% of fibromyalgia patients suffer from small intestinal bacterial overgrowth and digestive complaints (10, 11).  Some of the most common complaints among fibromyalgia patients include irritable bowel syndrome and indigestion or acid reflux (12, 13).

Additional Research done by Chris Kresser L.Ac found the following:

• A study in 2008 found a relationship between alterations of the intestinal microbiota (i.e. “gut flora”) and fibromyalgia. (14)
• Researchers at Cedars-Sinai Medical Center in Los Angeles found that 100% (42/42) of fibromyalgia patients they studied had small intestinal bacterial overgrowth (SIBO). (15)
• A study of 40 patients with fibromyalgia, 28 (70%) had intestinal permeability (i.e. leaky gut). Importantly, 12 of the 28 patients with leaky gut had no gut symptoms.   This is one reason the gut is often overlooked as a potential underlying cause of fibromyalgia. (16)

Mold Problems and Fibromyalgia

Mold grows in water damaged buildings and can release toxic substances called mycotoxins.  These mycotoxins such as aflatoxin, ochratoxins, and trichothecenes have delirious health effects on humans and are very rarely tested for or thought of by conventional medicine (17).

One study showed that 104 out of 112 (93%) individuals with fibromyalgia or chronic fatigue syndrome had at least one mycotoxin in their urine.  Almost 30% had two or more different mycotoxins in their urine (18).

Many of these people had high mold exposure from their homes or from their work offices.  I ask my clients if they feel better when they are on vacation (away from their office and home).  If one notices a big change when they are away from their normal surroundings it is a red flag for mold illness.

Biotoxins and Fibromyalgia

Biotoxins are hazardous organic substances that can cause significant damage to your health. Examples of biotoxins include mold and fungi, bacteria, volatile organic compounds (VOCs), endotoxins, and actinomycetes.

Examples of biotoxins include:

• Mold and yeast
• Lyme disease
• Viral infections
• Bacterial endotoxins

A 1992 observational cohort study indicated that chronic Lyme disease can lead to symptoms of fibromyalgia and is associated with the diagnosis.  A 2015 study found similar symptoms in many individuals suffering from chronic Lyme disease (19, 20).  A 2019 study found that poor immune reactions to the HPV vaccine could also be a factor involved in the development of neuroinflammation and fibromyalgia (21).

Heavy Metal Toxicity and Fibromyalgia:

Many individuals with fibromyalgia have heavy metal toxicity.  The most common heavy metals associated with this include mercury, aluminum, and lead.   Risk factors for mercury toxicity include a history of amalgam fillings or one’s mother having amalgam fillings.  Additionally, many vaccines used to have mercury and some still do.

If you had an old home with lead-based paints or have used a lot of lead-based lipstick you may have elevated levels. If one is consuming a lot of food out of aluminum cans or using aluminum cookware and getting flu vaccines that use aluminum as a preservative.  City based tap water can have high levels of any or all of these major heavy metals.

If you have various mineral deficiencies such as low zinc levels, it predisposes you to having higher heavy metal levels.  You can get a urine test to look at your heavy metal ratios.

Mitochondrial Dysfunction:

Every cell of the body has mitochondria within it that produce energy for the cell.  The mitochondria are the battery packs of the cell, and they are extremely important.  High levels of oxidative stress wear down the mitochondria and cause a dysfunctional state.

Studies have linked fibromyalgia with increased oxidative stress and mitochondrial dysfunction (22, 23).  In particular, individuals with fibromyalgia have been shown to be deficient in Coenzyme Q10 which is one of the most important free radical scavengers within the cell and a necessary nutrient for the mitochondrial respiratory chain (MRT) (24).

Low levels of CoQ10 reduce MRT activity and intracellular oxygenation levels.  Treatment with CoQ10 supplementation has been shown to be very successful in improving the symptomatology of fibromyalgia (25, 26).

Glutathione Depletion and Nrf2:

In fibromyalgia, the cells are under so much stress that their main protective shield, glutathione (GSH) gets worn down and oxidative stress damages the mitochondria and the DNA leading to cell death.  Poor blood sugar control and high environmental toxin exposure are known to deplete glutathione levels and impair mitochondrial function (27, 28).

A key pathway that maintains cellular glutathione levels and the ability of the cell to adapt to stress is called Keap1-Nrf2.  When this pathway breaks down it causes increased levels of oxidative stress within the cell that leads to glutathione depletion and mitochondrial dysfunction (29).

Low Vitamin D Levels and Fibromyalgia:

Vitamin D deficiency is a significant problem in our society, especially so among fibromyalgic patients.   Research shows that there is a correlation between vitamin D levels and the level of pain and symptoms of fibromyalgia where individuals with lower vitamin D have lower pain thresholds than fibro patients with higher vitamin D levels (30).

In one study, 61% of fibromyalgic patients had vitamin D levels under 30 ng/ml which is classically considered medically deficient.  These individuals saw significant improvement in their fibro symptoms when their vitamin D levels exceeded 50 ng/ml (31)

MTHFR and Fibromyalgia:

Methylation is a controlled transfer of a methyl group (one carbon and three hydrogen atoms) onto proteins, amino acids, enzymes, and DNA in every cell and tissue of the body to regulate healing, cell energy, genetic expression of DNA, liver detoxification, immunity, and neurology.

Adapting to stress and the challenges of life is an aspect that methylation provides the body.  Without adequate methylation processes the individual cannot adapt to stress effectively.  Research shows that individuals with fibromyalgia have altered methylation processes due to genetic polymorphysims (MTHFR, MTRR, A1AT, and COMT among others) and nutrient deficiencies (32, 33).

Key methylation elements include methylated B vitamins (riboflavin, B6, folate, and B12 in particular), magnesium, selenium, zinc, and various trace minerals.  Individuals with fibromyalgia are often deficient in these key nutrients and need nutritional and supplemental strategies to address these key methylating agents.

Low Oxalate Diet and Fibromyalgia:

Individuals with fibromyalgia may benefit from a low-oxalate diet.  Oxalates are naturally occurring compounds in plants, animals, and humans. The body is naturally able to synthesize oxalates from various compounds such as excess vitamin C, fructose as well as yeast.

Vitamin B-6 deficiency, magnesium, and thiamine deficiency are also ideal circumstances for increased oxalate synthesis. (34, 35, 36).  Clinically, I use the Great Plains Laboratory organic acid test to determine if someone has elevated oxalates in their system.  This is a simple urine test done in the comfort of your own home.

This test also lets me analyze for vitamin B6 deficiencies and for Candida overgrowth which are both major causes of hyperoxaluria and common issues involved with fibromyalgia (37, 38, 39).  From a functional nutrition and natural medicine perspective this test helps me to determine the cause and best diet and treatment for this condition.

Anti-Inflammatory Diet & Lifestyle

Anti-inflammatory foods help to modulate the immune system and reduce inflammatory activity in the body.  Great anti-inflammatory foods include coconut products, avocados, olive oil, berries & phytonutrient rich vegetables.  Healthy meat sources such as grass-fed beef, wild game, wild salmon, organic poultry, and organic eggs are great if the gut can tolerate them.

It is advisable for anyone with chronic inflammation to include organic vegetable juices, fermented foods, and functional beverages in their diet.   Homemade sauerkraut, apple cider vinegar, coconut water kefir, and kimchi are great.  Begin with small doses of all of these and add more if you tolerate them well.

Powerful herbs such as turmeric, ginger, garlic, onion, rosemary, thyme, cinnamon, & oregano among others should be used as much as possible to improve immune coordination.

Chiropractic Care for Fibromyalgia:

People with fibromyalgia, chronic pain & fatigue are highly likely to have neurological dysfunction in their upper neck.  Subluxation, or neurological interference, at the bottom of the skull, C1 & C2 alter endorphin release into the body.  This leads to increased states of pain, fatigue, anxiety, and accelerated stress as well as malcoordinated immunity (40).

Well trained chiropractors can analyze these regions of the spine and give specific corrective adjustments to restore balance and optimal neurological expression in these regions.  This reduces the stress response and improves endorphin release.  This improves the individual’s pain tolerance and overall well-being (41, 42).

Natural Support Strategies For Fibromyalgia:

Here are the best action steps to get started with on your journey to improve your health.  It is important to note that these strategies are not FDA-approved to prevent, mitigate, treat, or cure fibromyalgia and should not be considered as such.  You should always consult with your physician before stopping or changing medications or taking on new health strategies.

Additionally, you should be working with a functional health practitioner to help guide you through these strategies.  This is not an exhaustive list and there are other natural therapeutic strategies that I and functional health practitioners will utilize to help individuals with fibromyalgia.

Change Your Diet:

Eating an anti-inflammatory diet rich in nutrient-dense foods is the first best thing you can do to prevent inflammation and nervous system abnormalities. First, eliminate all inflammatory foods, including refined sugar, gluten, refined oils, deep-fried and processed foods, conventional dairy, grain-fed meat and eggs, soda and sugary drinks, and foods that you are sensitive to.

Instead, it is important to eat an anti-inflammatory diet that is rich in nutrient dense vegetables, low glycemic index fruits, herbs, spices, healthy fats, grass-fed meat, and wild-caught fish.  I also recommend a ketogenic approach for individuals with fibromyalgia. Getting into ketosis will enhance mitochondrial function and significantly reduce inflammation in the body.

Test For Food Sensitivities:

Most people with fibromyalgia and chronic fatigue syndrome have leaky gut and food sensitivities.  These sensitivities can be hard to pinpoint as they result in delayed symptoms that are not life threatening.

The most common food sensitivities include gluten, corn, dairy, soy, peanuts, and sugar.  Some other potential food sensitivities to consider include all grains, eggs, nuts, seeds, and nightshade vegetables (tomatoes, potatoes, peppers, and eggplant).

It can be helpful to do a 28-day elimination diet where you remove all of these and then slowly add these back in one at a time.  You can also do both biofeedback and blood testing to determine what foods are causing stress in your system and an elimination diet to test how you are responding to eliminating certain foods for periods of time.

Intermittent Fasting:  

Intermittent fasting is a form of fasting cycle between not eating (fasting) and eating (feasting) over a period of time. The benefits of intermittent fasting benefits include cellular repair, autophagy, immune regulation, inflammation levels, and insulin sensitivity.

It also helps to lower the risk of developing autoimmune and chronic inflammatory conditions such as rheumatoid arthritis.  Going 16–18 hours between dinner and breakfast is one of the best ways to improve mitochondrial production.  Your body improves energy efficiency by increasing and strengthening the mitochondria during periods of fasting.  Consume your meals in a 6–8-hour window such as 11 AM–7 PM or 12–6 PM.

When you do this, you enhance cellular healing and reduce neuroinflammation in the body.  To learn more about the benefits of intermittent fasting and best intermittent fasting practices, I recommend this article.

Reduce Stress:

Reducing stress is critical for reducing inflammation and improving immune health. I recommend that you reduce stressors from your life as much as possible. Turn off the news, and only look at it once a day or a few times a week for a specific period. Reduce your social media use and time on the internet.

Avoid people and situations that bring you down. Surround yourself with loving and uplifting people. Engage in uplifting and relaxation-promoting activities. Read, try some arts and crafts, play cards or board games, sing, and dance.

Spend time in nature and do some grounding walking barefoot on grass.  Practice daily gratitude and try positive affirmations.  Practice self-love and laugh with friends and family. Meditate, pray, journal, and try daily breathing exercises. Be grateful and smile more.

Improve Your Sleep:  

Prioritizing good sleep is just as important as reducing your stress levels. Develop a regular schedule of going to bed and getting up at the same time every day to support your circadian rhythms.

Avoid electronics, sugar, caffeine, heavy foods, and stress close to the bed. Engage in relaxing activities, including stretching, relaxing baths, meditation, and prayer. Make sure that you have a supporting bed, pillow, and bedding, and sleep in a dark calming room.

Power Up Your Nrf2 Pathway:

Nrf2 (NF-E2-related factor 2) is a transcription factor in humans encoded by a specific gene that regulates the expression of a set of antioxidant and detoxifying genes.  This pathway is activated under times of oxidative stress to enhance the expression of a multitude of antioxidant and phase II liver detoxification enzymes that restore homeostasis to the ox/redox cycles in the body (43, 44, 45).

The Nrf2 pathway has been researched to be a key player in the development or prevention of chronic inflammation, neuroinflammation, and autoimmune activity (46, 47, 48).  Adding in clinical dosages of resveratrol, curcumin, quercetin, sulfuraphane and green tea (EGCG) can be extraordinarily beneficial for driving up the Nrf2 Pathway.

Include Magnesium & B Vitamin Rich Foods:  

Magnesium helps to improve blood sugar signaling patterns and improves mitochondrial health.  The best magnesium and B vitamin rich foods include dark green leafy veggies, avocados, grass-fed animal products, raw cacao, and pumpkin seeds.

You can also do Epsom salt baths to support your magnesium levels.  It would also be wise to supplement with a good magnesium and B complex supplement.  Look for magnesium L-threonate which is the best form of magnesium for crossing the blood-brain barrier.

When it comes to B vitamins, it is best to look for one with pre-activated forms such as methyl-folate, methyl-cobalamin (B12), Pyridoxal-5-Phosphate form of B6, and Riboflavin-5-phosphate form of vitamin B2.  The methyl groups are in the active form and will be better utilized by the body.

Focus on Deep Breathing:

Improving your posture, seeing a high-quality chiropractor, and optimizing your breathing patterns is highly recommended.  Taking time to slow down your breathing and take long-deep breaths for a few minutes every hour will help reduce the sympathetic, fight or flight part of the nervous system.

The better we breathe, the better we will heal and the more blood flow we will get, and the better our immune and inflammatory health will be.  Follow these tips here to improve your breathing patterns.

Use Antioxidant Rich Herbs:

Carminatives are herbs that help to improve digestive health by reducing pathogens in the gut, stimulating the production of stomach acid, bile, and pancreatic enzymes, and modulating the gut microbiome.

Examples of these herbs include turmeric, ginger, oregano, garlic, basil, thyme and rosemary.  These herbs help to improve digestion, reduce inflammation, and support a healthy brain.  There are a number of ways to use these that I discuss in the following image.  I like putting herbs on foods, using herbal teas, fermented foods, and essential oils.

Ground Your Body:

In our society, we are surrounded by toxic electromagnetic frequency’s (EMF’s).  These EMF’s increase stress and inflammation within the body and can be a trigger for neurological inflammation in some individuals.  Many people suffering from fibromyalgia have a lot of trouble dealing with environments that are high in EMF.

By going outside daily and walking barefoot on grass, dirt, or sand you absorb natural EMFs from the ground that balance your electrical rhythms.  Follow the steps in this article here.

Supplement With Omega 3’s:

Omega 3 fatty acids and in particular the long chain variety EPA and DHA are critical for stabilizing blood sugar, and reducing inflammation and pain. Consume grass-fed meat, grass-fed butter, wild-caught fish, seafood, and spirulina to get it in your diet.

Plant based omega 3’s such as flax oil only contain the small chain omega 3 called ALA and do not have any DHA.  It is very hard for our body to convert ALA into DHA, so it is best to get a high-quality fish or krill oil that is rich in EPA and DHA.  You want to find a brand that is molecularly distilled to take out any heavy metals and other unwanted contaminants.

Be sure to discuss with your physician before using as fish oils have a blood thinning effect and can be contraindicated if you are on blood thinning medications.

Improve Your Mitochondria:  

The mitochondria are the energy powerhouses of every cell.  When someone has an autoimmune or chronic inflammatory disorder it is a clinical sign that they have dysfunctional activity going on in the mitochondria.

Support your mitochondria with clinical doses of CoQ10, L-carnitine, N-acetyl cysteine, creatine monohydrate, B vitamins, magnesium, alpha lipoic acid, and D-ribose.  You can find mitochondrial support supplements that have most if not all of these key nutrients.

Optimize Your Vitamin D:  

Low vitamin D3 is associated with chronic inflammation and autoimmune conditions.  Vitamin D is arguably one of the most powerful nutrients responsible for modulating and coordinating the immune system.

In autoimmune disease, the immune system has a hard time differentiating itself from non-self (foreign invaders). Vitamin D helps the immune system make this important distinction, which reduces autoimmune disease formation (49).  Vitamin D also helps to modulate the immune system to reduce inflammation throughout the body (50).

Support Gut Health

To reduce inflammation and autoimmunity, you have to repair and heal your intestinal lining.  I recommend eating a gut friendly diet that works best for your body type.  For some individuals with fibromyalgia, a low oxalate diet is very helpful.

Consuming liquid nutrition is great for stimulating the digestive process, increasing nutrient absorption, and improving gut health. Liquid nutrition does not require as much energy to digest, so your body can focus on healing and repair. You can combine liquid nutrition with fasting strategies for quicker healing.

Using a good quality bone broth collagen in a shake or smoothie is a great way to include liquid nutrition in your diet. Collagen contains amino acids, including glycine and glutamine, which are essential for healing leaky gut. These amino acids seal the holes in the gut by healing damaged cells and building new tissue. Collagen also makes up the villi, small finger-like structures on the intestinal wall, and assists with water absorption in the intestines.

Additionally, I recommend taking a daily probiotic supplement.  Probiotics help to optimize your gut health and improve your nutrient absorption while reducing gut related inflammation.  When gut inflammation goes down it also reduces inflammatory mediators that impact joint health.

Reduce Toxin Exposure

Reducing your toxic exposure is critical for improving liver function and reducing inflammation. Buy organic food as much as possible. Stop using conventional beauty, body, and household products, and replace them with organic, natural, or homemade alternatives.

Use glass, stainless steel, wood, and bamboo products instead of plastic. Spend time in nature and breathe in the fresh air. Use a good indoor air filtration system. Make sure that you drink clean, toxin-free water by using a high-quality reverse osmosis system.  Add a slice of lime for some extra flavor.

Support Detoxification Pathways

It is not enough to put good things into your body, you have to make sure that the bad things come out as well. Drink plenty of water to support detoxification through sweating and urine. Support your detoxification pathways to protect your body from brain inflammation.

I recommend using infrared saunas to promote detoxification through sweating. Try rebounding and dry-skin brushing to support your lymphatic pathways.  Support two major detoxifying organs, your kidneys and liver with herbs like milk thistle, parsley, dandelion, and bioactive carbons which can penetrate and remove toxins from deep within the tissues and cells.

Final Thoughts

Fibromyalgia is a serious issue that affects millions of people around the world. The symptoms of fibromyalgia include pain, fatigue, sleep problems, depression, brain fog, and headaches. To help support your body, follow my recommendations in this article. You may notice improvements in your pain, energy, and overall health.

If you want to work with a functional health coach, I recommend this article with tips on how to find a great coach. On our website, we offer long-distance functional health coaching programs. For further support with your health goals, just reach out—our fantastic coaches are here to support your journey.

Inflammation Crushing Ebundle

The Inflammation Crushing Ebundle is designed to help you improve your brain, liver, immune system and discover the healing strategies, foods and recipes to burn fat, reduce inflammation and thrive in life!

As a doctor of natural medicine, I have spent the past 20 years studying the best healing strategies and worked with hundreds of coaching clients, helping them overcome chronic health conditions and optimize their overall health.

In our Inflammation Crushing Ebundle, I have put together my very best strategies to reduce inflammation and optimize your healing potential.  Take a look at what you will get inside these valuable guides below!

Sources For This Article Include:

1.Women’s Health – Fibromyalgia fact sheet Link Here

2. Ngian GS, Guymer EK, Littlejohn GO. The use of opioids in fibromyalgia. Int J Rheum Dis. 2011 Feb;14(1):6-11. PMID: 21303476

3. Liptan GL. Fascia: A missing link in our understanding of the pathology of fibromyalgia. J Bodyw Mov Ther. 2010 Jan;14(1):3-12. PMID: 20006283

4. Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep. 2002 Aug;6(4):259-66. PMID: 12095460

5. Demitrack MA, Crofford LJ. Evidence for and pathophysiologic implications of hypothalamic-pituitary-adrenal axis dysregulation in fibromyalgia and chronic fatigue syndrome. Ann N Y Acad Sci. 1998 May 1;840:684-97. PMID: 9629295

6. Tanriverdi F, Karaca Z, Unluhizarci K, Kelestimur F. The hypothalamo-pituitary-adrenal axis in chronic fatigue syndrome and fibromyalgia syndrome. Stress. 2007 Mar;10(1):13-25. PMID: 17454963

7. Moldofsky H. Sleep, neuroimmune and neuroendocrine functions in fibromyalgia and chronic fatigue syndrome. Adv Neuroimmunol. 1995;5(1):39-56. PMID: 7795892

8. Bhattacharjee S, Lukiw WJ. Alzheimer’s disease and the microbiome. Frontiers in Cellular Neuroscience. 2013;7:153.

9. Hill JM, Bhattacharjee S, Pogue AI, Lukiw WJ. The Gastrointestinal Tract Microbiome and Potential Link to Alzheimer’s Disease. Frontiers in Neurology. 2014;5:43.

10. Wallace DJ, Hallegua DS. Fibromyalgia: the gastrointestinal link. Curr Pain Headache Rep. 2004 Oct;8(5):364-8. PMID: 15361320

11. Kurland JE, Coyle WJ, Winkler A, Zable E. Prevalence of irritable bowel syndrome and depression in fibromyalgia. Dig Dis Sci. 2006 Mar;51(3):454-60. PMID: 16614951

12. Wallace DJ, Hallegua DS. Fibromyalgia: the gastrointestinal link. Curr Pain Headache Rep. 2004 Oct;8(5):364-8. PMID: 15361320

13. Chang L. The association of functional gastrointestinal disorders and fibromyalgia. Eur J Surg Suppl. 1998;(583):32-6. PMID: 10027670

14. Othman M, Agüero R, Lin HC. Alterations in intestinal microbial flora and human disease. Curr Opin Gastroenterol. 2008 Jan;24(1):11-6. PMID: 18043226

15. Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing. Ann Rheum Dis. 2004 Apr;63(4):450-2. PMID: 15020342

16. 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 Aug;47(8):1223-7. PMID: 18540025

17. Hooper DG, Bolton VE, Guilford FT, Straus DC. Mycotoxin detection in human samples from patients exposed to environmental molds. Int J Mol Sci. 2009 Apr 1;10(4):1465-75. PMID: 19468319

18. Brewer JH, Thrasher JD, Straus DC, Madison RA, Hooper D. Detection of Mycotoxins in Patients with Chronic Fatigue Syndrome. Toxins. 2013;5(4):605-617.

19. Dinerman H, Steere AC. Lyme disease associated with fibromyalgia. Ann Intern Med. 1992;117(4):281-285. PMID: 1637022

20. Wormser GP, Weitzner E, McKenna D, et al. Long-Term Assessment of Fibromyalgia in Patients with Culture-Confirmed Lyme Disease. Arthritis Rheumatol. 2015;67(3):837-839. PMID: 25470117

21. Ryabkova VA, Churilov LP, Shoenfeld Y. Neuroimmunology: What Role for Autoimmunity, Neuroinflammation, and Small Fiber Neuropathy in Fibromyalgia, Chronic Fatigue Syndrome, and Adverse Events after Human Papillomavirus Vaccination?. Int J Mol Sci. 2019;20(20):5164. Published 2019 Oct 18. PMCID: 6834318

22. Cordero MD, de Miguel M, Carmona-López I, Bonal P, et al. Oxidative stress and mitochondrial dysfunction in fibromyalgia. Neuro Endocrinol Lett. 2010;31(2):169-173. PMID: 20424583

23. Cordero MD, de Miguel M, Moreno-Fernández AM. [Mitochondrial dysfunction in fibromyalgia and its implication in the pathogenesis of disease]. Med Clin (Barc). 2011 Mar 12;136(6):252-6. PMID: 20417529

24. Miyamae T, Seki M, Naga T, Uchino S, Asazuma H, Yoshida T, Iizuka Y, Kikuchi M, Imagawa T, Natsumeda Y, Yokota S, Yamamoto Y. Increased oxidative stress and coenzyme Q10 deficiency in juvenile fibromyalgia: amelioration of hypercholesterolemia and fatigue by ubiquinol-10 supplementation. Redox Rep. 2013;18(1):12-9. PMID: 23394493

25. Hargreaves IP. Coenzyme Q10 as a therapy for mitochondrial disease. Int J Biochem Cell Biol. 2014 Apr;49:105-11. PMID: 24495877

26. Cordero MD, Cotán D, del-Pozo-Martín Y, Carrión AM, de Miguel M, Bullón P, Sánchez-Alcazar JA. Oral coenzyme Q10 supplementation improves clinical symptoms and recovers pathologic alterations in blood mononuclear cells in a fibromyalgia patient. Nutrition. 2012 Nov-Dec;28(11-12):1200-3. PMID: 22898267

27. Sendur OF, Turan Y, Tastaban E, Yenisey C, Serter M. Serum antioxidants and nitric oxide levels in fibromyalgia: a controlled study. Rheumatol Int. 2009 Apr;29(6):629-33. PMID: 18853166

28. La Rubia M, Rus A, Molina F, Del Moral ML. Is fibromyalgia-related oxidative stress implicated in the decline of physical and mental health status? Clin Exp Rheumatol. 2013 Nov-Dec;31(6 Suppl 79):S121-7. PMID: 24373370

29. Harvey CJ, Thimmulappa RK, Singh A, et al. Nrf2-regulated glutathione recycling independent of biosynthesis is critical for cell survival during oxidative stress. Free radical biology & medicine. 2009;46(4):443-453. PMCID: 2634824

30. Okumus M, Koybası M, Tuncay F, Ceceli E, Ayhan F, Yorgancioglu R, Borman P. Fibromyalgia syndrome: is it related to vitamin D deficiency in premenopausal female patients? Pain Manag Nurs. 2013 Dec;14(4):e156-63. PMID: 24315268

31. Matthana MH. The relation between vitamin D deficiency and fibromyalgia syndrome in women. Saudi Med J. 2011 Sep;32(9):925-9. PMID: 21894355

32. Miller AL. The methylation, neurotransmitter, and antioxidant connections between folate and depression. Altern Med Rev. 2008 Sep;13(3):216-26. PMID: 18950248

33. Schmechel DE, Edwards CL. Fibromyalgia, mood disorders, and intense creative energy: A1AT polymorphisms are not always silent. Neurotoxicology. 2012 Dec;33(6):1454-72. PMID: 22414631

34. Effects of Sugars and Vitamin B-6 Deficiency on Oxalate Synthesis in Rats Link Here

35. Rushton HG, Spector M. Effects of magnesium deficiency on intratubular calcium oxalate formation and crystalluria in hyperoxaluric rats. J Urol. 1982 Mar;127(3):598-604. PMID: 7062446

36. Sidhu H, Gupta R, Thind SK, Nath R. Oxalate metabolism in thiamine-deficient rats. Ann Nutr Metab. 1987;31(6):354-61. PMID: 3426152

37. Effects of Hydroxyproline and Vitamin B-6 on Oxalate Synthesis in Rats Link Here

38. Loewus FA, Saito K, Suto RK, Maring E. Conversion of D-arabinose to D-erythroascorbic acid and oxalic acid in Sclerotinia sclerotiorum. Biochem Biophys Res Commun. 1995;212(1):196-203.  PMID: 7612007

39. Muntz FH. Oxalate-producing pulmonary aspergillosis in an alpaca. Vet Pathol. 1999 Nov;36(6):631-2. PMID: 10568451

40. Models of Vertebral Subluxation:A Review Link Here

41. Science Direct – Neurophysiological effects of spinal manipulation Link Here

42. Chiropractic Management of Fibromyalgia Syndrome: A Systematic Review of the Literature Link Here

43. Kang KW, Lee SJ, Kim SG. Molecular mechanism of nrf2 activation by oxidative stress. Antioxid Redox Signal. 2005;7(11-12):1664-1673. PMID: 16356128

44. Katoh Y, Iida K, Kang MI, et al. Evolutionary conserved N-terminal domain of Nrf2 is essential for the Keap1-mediated degradation of the protein by proteasome. Arch Biochem Biophys. 2005;433(2):342-350. PMID: 15581590

45. Surh YJ, Kundu JK, Na HK. Nrf2 as a master redox switch in turning on the cellular signaling involved in the induction of cytoprotective genes by some chemopreventive phytochemicals. Planta Med. 2008;74(13):1526-1539. PMID: 18937164

46. Miller DM, Singh IN, Wang JA, Hall ED. Nrf2-ARE activator carnosic acid decreases mitochondrial dysfunction, oxidative damage and neuronal cytoskeletal degradation following traumaticbrain injury in mice.Exp Neurol. 2014 Nov 26;264C:103-110. PMID: 25432068

47. Kärkkäinen V, Pomeshchik Y, Savchenko E, Dhungana H, et al. Nrf2regulates neurogenesis and protects neural progenitor cells against Aβ toxicity. Stem Cells. 2014 Jul;32(7):1904-16.   PMID: 24753106

48. Sandberg M, Patil J, D’Angelo B, Weber SG, Mallard C. NRF2-regulation in brain health and disease: implication of cerebral inflammation. 2014 Apr;79:298-306. Review.  PMID: 24262633

49. Maruotti N, Cantatore FP. Vitamin D and the immune system. J Rheumatol. 2010;37(3):491-495. PMID: 20080911

50. Baeke F, Takiishi T, Korf H, Gysemans C, Mathieu C. Vitamin D: modulator of the immune system. Curr Opin Pharmacol. 2010;10(4):482-496. PMID: 20427238