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12 Articles in Volume 17, Issue #2
Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum
Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease
Duloxetine and Liver Function Tests
How Well Do You Know Your Patient?
Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Letters to the Editor: Initiating Hormones
Managing Opioid Use Disorders and Chronic Pain
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model

Learn how applying a functional medicine model to manage the underlying causes of multiple systemic pain syndromes, using a more patient-centric team approach, helps improve care.
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The current standard of medical care is a disease-based model. When patients present with uncomplicated acute pain, such as from a traumatic fracture, then a traditional medical approach is usually effective at providing relief. However, when symptoms persist beyond 3 months and become chronic, as with complex regional pain syndrome (CRPS) or fibromyalgia, then treatment will require a more patientcentric model of care, using multimodal therapies and interdisciplinary teamwork.

This is the basis for a functional medicine model that looks beyond the symptom-disease concept to identify and correct any mechanisms driving the disease process. These underlying issues may arise from imbalances and interactions between genes, diet, lifestyle, and environmental factors.1 When implementing evidence-based therapies that target pain mechanisms to resolve the disease-pain process, overall health and physical function are improved.

Two patients diagnosed with migraines, chronic fatigue syndrome, neuropathic pain, degenerative arthritis, and fibromyalgia, following failed trials of the prescribed analgesics: duloxetine and pregabalin, were assessed and treated using the functional medicine model. Their cases are presented here.

Patient Case 1

Patient A, a 43-year-old married mother of 2 teenage boys, presented with a chief complaint of chronic widespread pain that had worsened over the past 15 years. Her pain symptoms included daily headaches (with the pain radiating from the occipital region on the left side to the frontal area), joint pain and stiffness, irregular periods, and chronic sinus congestion.

Medical History

This patient had been diagnosed previously for common migraines, depression, anxiety, chronic rhinitis, asthma, mild eczema, and benign positional vertigo. She reported experiencing headaches nearly every day, which worsened in the presence of strong odors, such as perfumes, auto exhaust, and dampness, and that these headaches had begun in childhood. She also was experiencing joint pain in the shoulders, knees, hands, and fingers with an overall average numerical pain rating score of 6 out of 10 on a near-daily basis. She reported experiencing allergies when exposed to mold, dust, and nickel. Also, she was troubled by low energy and brain fog.

Three years ago, she had a mammogram, physical exam, and Pap smear, all of which were normal. She reported having had no surgeries, motor vehicle accidents, or known concussions. The patient had no symptoms to suggest seronegative, autoimmune, or demyelinating diseases.

Her family history was positive for atopy, Asperger’s syndrome (both sons), type 2 diabetes, obesity, migraines (both parents), brain cancer (grandparent), and breast cancer (aunt). She was a former smoker who quit 17 years ago and did not drink alcohol or use recreational drugs. She averaged 3 to 4 cups of coffee every morning. In her leisure time, she enjoyed playing guitar, hiking, and photography.

Patient A reported using a variety of prescription medications, including nonsteroidal anti-inflammatory drugs, triptans, topiramate, gabapentin, and paroxetine (20 mg/day), and was taking a micronutrient supplement of vitamins D, B complex, and a multivitamin. In addition, she had sought pain relief from chiropractic care, physiotherapy, and acupuncture and had accommodations for workplace ergonomic corrections. She had had a thorough workup with negative results from a variety of specialists, including an endocrinologist, a neurologist, and an otolaryngologist.

Diagnosis and Treatment

Physical findings for patient A were unremarkable (Table 1) and test results for sleep apnea were normal. She was diagnosed with cervicogenic headaches with migraine features. Then she was referred to a naturopathic doctor who recommended dietary changes, including avoidance of aspartame and sugar-containing foods, as well as dairy products, to reduce possible triggers to her migraines exacerbations. She also was referred to an environmental medicine consultant for a more advanced exploration of her response to allergens.

Environmental Consultation

The patient was seen in March 2015 by an environmental medicine specialist to review potential exposures, causal links, and genetic polymorphisms (Tables 2 and 3). During the evaluation, she reported that symptoms, including the headaches and joint pain, started during a home renovation that exposed mold that had developed following recent water damage.

Given her symptoms of multiple environmental chemical sensitivities syndrome, the patient was directed to complete an environmental questionnaire and lifestyle genomics profile and to undergo standard lab tests, including a urine oxidative damage panel.

An assessment of her unique genomic profile revealed several genetic polymorphisms associated with impairments in detoxification and methylation; more specifically, she had GSTM1 and GSTT1 deletions, which made her more susceptible to exogenous toxins.1 These deletions challenged her ability to upregulate glutathione induction in response to exposure.2,3

She also was homozygous for an at-risk allele for SOD2, which impaired biosynthesis of superoxide dismutase, a potent endogenous antioxidant required for mitochondrial cellular protection.4 The methylation profile also revealed several at-risk alleles related to absorption, assimilation, transport, and metabolism of cobalamin and folate, which may compromise the functional capacity of the methylation cycle, leading to disturbances in cellular repair, stress response, and bioenergetics.5

When Patient A returned to the functional medicine clinic in April 2015, she mentioned that she was attempting to taper off the paroxetine. She also reported a flare in joint pain, but no effusions were noted. Her genetic profile and biotransformation imbalances were reviewed with her in detail. She was told that the inflammatory markers test and the oxidative stress profile came back normal. However, she had a markedly elevated complement protein, C4a, suggesting mycotoxicity to mold. Also, she had a high normal mean corpuscular volume of 97, which was suggestive of hypomethylation.

Last updated on: June 21, 2017
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Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

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