Intestinal permeability in Fibromyalgia

If reading the science is not your cup of tea, just jump down the page to my discussion.

Fibromyalgia is a chronic pain syndrome which is characterised by widespread pain at multiple tender points, joint stiffness and systemic symptoms such as mood disorders, fatigue, cognitive dysfunction and insomnia, in the absence of a well-defined underlying organic disease.

Although many pharmacological treatments have been studied and embraced for the treatment of fibromyalgia, no single drug or group of drugs has proved to be particularly useful in treating fibromyalgia patients as a whole. The most common drugs prescribed for fibromyalgia are anti-depressants and voltage-gated calcium channel blockers, with limited success.

Exercise, meditation, yoga and the like have all shown benefits for fibromyalgia patients. (Hennard, 2011; Mist, 2013).

Research into increased intestinal permeability (leaky gut syndrome) and small intestine bacterial overgrowth (SIBO) has shown a correlation between fibromyalgia, complex regional pain syndrome, chronic fatigue syndrome, auto-immune diseases, IBS, clinical depression and many other diseases, to altered intestinal permeability and/or SIBO. (Goebel, 2008; Pressman, 2010; Anderson, 2015; Vasquez, 2016).

Maes & Leunis (2008), found that “normalisation of leaky gut in chronic fatigue syndrome is accompanied by a clinical improvement”, and that “a weakened tight junction barrier with subsequent gut-derived inflammation is a novel pathway in CFS, and patients with leaky gut can be treated with specific NAIO’s (natural anti-inflammatory and anti-oxidative substances (NAIOSs), such as glutamine, N-acetyl cysteine and zinc) and a leaky gut diet”.

A letter to Nature reviews Rheumatology journal by Alex Vasquez (2016), pointed to research articles which showed a correlation between SIBO and increased intestinal permeability and Fibromyalgia and complex regional pain syndromes.

• A 2004 study among 42 patients found that all (100%) showed laboratory evidence of SIBO, severity of which corresponded to severity of fibromyalgia

• A 2008 study documented that patients with fibromyalgia and CRPS have intestinal permeability

• A 2013 study showed that CRPS patients have distinct alterations in their gastrointestinal microbiome characterised by reduced diversity and significantly increased levels of proteobacteria.

• Vitamin D deficiency is prevalent in chronic pain and fibromyalgia patients and promotes pain sensitisation, myalgia and bone pain. Human clinical trials have shown that vitamin D supplementation can alleviate inflammation, intestinal hyperpermeability, fibromyalgia pain and other neuromuskuloskeletal pain.

• Mitochondrial dysfunction, noted fibromyalgia and CRPS, may be triggered by gastrointestinal dysbiosis via LPS (lipopolysaccharide-stimulated proinflammatory cytokines), D-lactate, hydrogen sulphide and inflammation; mitochondrial dysfunction promotes pain sensitisation centrally while also contributing to muscle pain peripherally. Treatment of mitochondrial dysfunction with ubiquinone alleviated many biochemical and clinical manifestations of fibromyalgia.

(Vasquez, 2016)

So a lot of people right about now are saying to themselves, well that’s all lovely and sciency, but what does it all mean and how can I begin to feel better?

First of all, there is no quick fix for any chronic disease, it has taken a long time to get to where you are right now and may take a long time to get better, but not always so.

In my own case I had severe Rheumatoid arthritis for 12 years (between the ages of 14 and 26), in many cases that would mean at least 12 months to improve, but on healing my own intestinal permeability, it was 3-4 weeks.

Having said that, I am currently having my first flare up in 21 years and I have been working on myself now for about 6 months. But don’t be disheartened if that sounds like a long time, in the last 6 months I have gone from needing to use a walking frame to requiring no walking aids at all, all progress is a celebration!

So let’s go back to the beginning, intestinal permeability. There are numerous things which can cause intestinal permeability including viruses, various bacteria, food allergies and intolerances, chemicals, parasites, etc.

The gastrointestinal tract, whilst appearing to be on the inside of our bodies is actually “outside”. sounds weird I know, but technically it is, the GIT is the interface between the outside world i.e., foods, chemicals, bacteria's, viruses, etc., and our internal machinations, it runs from mouth to anus and is responsible for many functions including absorption of nutrients, detection of infections/toxins and waste disposal to name a few, so it is imperative that the mucosal lining is in tip top shape. In very simple terms, the mucosal barrier is made up of tight junctions which are selectively permeable. This means that they only allow certain things to get through the gut barrier into the internal area of our bodies. When the mucosal lining of the gut is damaged, these tight junctions become loose, the GALT (Gastrointestinal associated lymphoid tissue) malfunctions and particles enter the body that ordinarily would have been disposed of in one way or another.

Mucosal surfaces, particularly in the intestines, are important sites of innate and adaptive immune regulation via the GALT- Gastrointestinal associated lymphoid tissue which is an important part of our immune system. When the GALT starts to malfunction due to damage to the mucosal lining, we lose our normal tolerance and we start to react to things we should be tolerant to.

Increased gut permeability is a driver of systemic inflammation. Lipopolysaccharide-stimulated proinflammatory cytokines are found most abundantly in the gastrointestinal tract and damage to the gut lining allows increased absorption of LPS into the system. LPS has been found to promote muscle mitochondrial impairment.

The mitochondria is the powerhouse of our cells, it is where our source of energy, ATP, is produced, it also determines the fate of a cell. Mitochondria respond to oxidative stress and this response determines what the cell will do- i.e apoptosis (cell death) or the cell will pause its function to make repairs, it is so important that our mitochondria function properly.

Gut permeability also leads to altered gut flora. Our microbiome is so important to our overall health and well-being. For every one human cell there are 10,000 bacteria so having the right balance of bacteria is crucial. Certain strains of bacteria help us break down starches, metabolise and make vitamins, ward off pathogenic bacteria and so much more.

Although this is only a ‘snap shot’ of the problems associated with intestinal permeability, it’s pretty clear that repairing the mucosae of the gut is an extremely important part in the management of fibromyalgia and other chronic and autoimmune diseases.

In order to heal the gut, we first need to try to understand the underlying cause of the damage. This involves taking a thorough case history, and may also involve elimination diets, testing for viruses, bacteria and parasites, stool analysis to determine what bacteria make up your microbiome, breath testing for SIBO, etc., there is also testing available for gut permeability, but usually this is not needed unless you want to truly know for sure.

Often, gluten and dairy protein is a problem in those of us with chronic disease. Whilst it can be difficult to remove these things from our diet because we love them, they don’t love us! One reason for this is a phenomena known as molecular mimicry, but that’s a subject for another blog.

In order to figure out if these are a problem for the individual (who is not celiac or lactose intolerant), it’s so important to remove them completely from the diet for a period of time. Eventually you may be able to slowly reintroduce one at a time, paying attention to how your body responds.

Some people believe a small amount of an offending food won’t hurt, as long as you cut down, sadly this is just not the case when trying to heal gut permeability. If that substance is causing or contributing to the leaky gut, it will continue to damage the gut regardless of how much you ingest. At the end of the day, we need to ask ourselves, do we really want that pastry, milkshake, etc. …….or do we want to be pain free?

There are many diets, herbs and supplements which can help to heal the mucosal lining of the gut.

These may include, but are certainly not limited to-

• Administration of certain probiotics can alter the gut microbiota positively, improve mucosal barrier function, decrease pro-inflammatory cytokines, and have the potential to positively influence mood. (Lakhan, 2010)

• Zinc has an important function in many systems of the body including, but not limited to, a healthy immune system, the production of stomach acid and has also been shown to help improve gut permeability. (Zhang, 2009; Ziegler, 2003)

• Glutamine, N-acetyl cysteine and zinc (Maes, 2008)

• Demulcent (moistening, soothing) herbs such as Slippery elm, Marshmallow, Licorice (do not use if you have high blood pressure), Flaxseed.

• Astringent and bitter herbs also play a role in healing the mucosal lining and can be as simple as incorporating bitter leaves into your salads before meals

• Vitamin C is important for the immune system and for collagen repair/synthesis.

Mitochodrial dysfunction

• Treatment of mitochondrial dysfunction with ubiquinone (CoQ10) alleviated many biochemical and clinical manifestations of fibromyalgia. (Vasquez, 2016)

• Vitamins C, D and E, thiamine, riboflavin

• Magnesium, calcium, phosphate

• Unsaturated fatty acids

• Glutathione

• Alpha-lipoic acid

• Herbs - Curcumin and Schisandra

Nicholson, (2014)

Diets that have been beneficial in allowing the gut to heal are those in which inflammatory foods such as wheat, dairy, sugar and for many people, red meat, have been removed. A diet high in antioxidant and vitamin rich foods is essential when dealing with a chronic disease.

For help determining which supplements, foods and herbs are right for you please see your natural health practitioner.

Vicky

Phoenix Healing Centre 2019

Anderson, G., & Maes, M. (2015). The gut–brain axis: the role of melatonin in linking psychiatric, inflammatory and neurodegenerative conditions. Advances In Integrative Medicine, 2(1), 31-37.

Giloteaux, L., Goodrich, J. K., Walters, W. A., Levine, S. M., Ley, R. E., & Hanson, M. R. (2016). Reduced diversity and altered composition of the gut microbiome in individuals with myalgic encephalomyelitis/chronic fatigue syndrome. Microbiome, 4(1), 30.

A. Goebel, S. Buhner, R. Schedel, H. Lochs, G. Sprotte, Altered intestinal permeability in patients with primary fibromyalgia and in patients with complex regional pain syndrome, Rheumatology, Volume 47, Issue 8, August 2008, Pages 1223-1227, https://doi.org/10.1093/rheumatology/ken140

Hennard, J. (2011). A protocol and pilot study for managing fibromyalgia with yoga and meditation. International journal of yoga therapy, 21(1), 109-121.

Lakhan, S. E., & Kirchgessner, A. (2010). Gut inflammation in chronic fatigue syndrome. Nutrition & metabolism, 7(1), 79.

Maes, M., & Leunis, J. C. (2008). Normalization of leaky gut in chronic fatigue syndrome (CFS) is accompanied by a clinical improvement: effects of age, duration of illness and the translocation of LPS from gram-negative bacteria. Neuroendocrinology Letters, 29(6), 902.

Mist, S. D., Firestone, K. A., & Jones, K. D. (2013). Complementary and alternative exercise for fibromyalgia: a meta-analysis. Journal of pain research, 6, 247.

Nicolson, G. L. (2014). Mitochondrial dysfunction and chronic disease: treatment with natural supplements. Integrative Medicine: A Clinician's Journal, 13(4), 35.

Pressman, A. H. (1993). Metabolic toxicity and neuromuscular pain, joint disorders, and fibromyalgia. JOURNAL OF CHIROPRACTIC, 30, 77-77.

Vasquez, A. (2016). Neuroinflammation in fibromyalgia and CRPS is multifactorial. Nature Reviews Rheumatology, 12(4), 242.

Ziegler, T. R., Evans, M. E., Fernández-Estívariz, C., & Jones, D. P. (2003). Trophic and cytoprotective nutrition for intestinal adaptation, mucosal repair, and barrier function. Annual review of nutrition, 23(1), 229-261.

Zhang, B., & Guo, Y. (2009). Supplemental zinc reduced intestinal permeability by enhancing occludin and zonula occludens protein-1 (ZO-1) expression in weaning piglets. British Journal of Nutrition, 102(5), 687-693.