Functional Integrative Health · Supplementary · from Functional Integrative Health

Case 3: Fibromyalgia with Multimodal Treatment

Patient Presentation

Demographics: 45-year-old female registered nurse

Chief Complaint: "I hurt everywhere and no one can figure out why."

History of Present Illness: The patient presents with a 5-year history of widespread musculoskeletal pain that has progressively intensified. She describes the pain as a constant, deep ache affecting her neck, shoulders, back, hips, and legs, rated at 6-8/10 on most days. She reports prominent morning stiffness lasting 60-90 minutes daily. The pain is worsened by cold weather, prolonged standing (required by her job), poor sleep, and emotional stress.

She reports severe sleep disruption, describing difficulty falling asleep and frequent awakenings with a sensation of "never reaching deep sleep." She estimates getting 4-5 hours of fragmented sleep nightly. Daytime fatigue is profound, and she has had to reduce her work schedule from full-time to three 12-hour shifts per week. She also reports cognitive difficulties including poor concentration and memory, headaches (2-3 per week), paresthesias in her hands, and temperature sensitivity.

She has seen a rheumatologist who performed extensive workup including ANA, RF, anti-CCP, and inflammatory markers, all of which were negative. She has tried gabapentin (stopped due to weight gain and dizziness), amitriptyline (stopped due to excessive sedation), and duloxetine (partial benefit at 60 mg but still symptomatic). She expresses frustration with the medical system and feels her pain is not taken seriously.

Past Medical History:

• Fibromyalgia (diagnosed 3 years ago)
• Chronic migraine
• Temporomandibular joint dysfunction
• Major depressive episode (5 years ago, in remission)
• Childhood adverse experiences (emotional neglect)

Medications:

• Duloxetine 60 mg daily
• Sumatriptan 50 mg PRN for migraines
• Cyclobenzaprine 5 mg at bedtime PRN
• Ibuprofen 400 mg PRN (taking daily)

Social History:

• Non-smoker, no alcohol
• Works as an RN on a medical-surgical floor (3x12-hour shifts)
• Divorced, single mother of two children (ages 10 and 13)
• Limited social support
• No regular exercise due to pain and fatigue

Family History:

• Mother: Fibromyalgia, depression
• Sister: Chronic fatigue syndrome
• Father: Alcoholism, chronic pain

Physical Examination

• Vital Signs: BP 134/82 mmHg, HR 76 bpm, RR 14, Temp 36.6°C, SpO2 98% RA, BMI 28.4
• General: Appears older than stated age, moves slowly and stiffly, pain behaviors noted with position changes
• HEENT: Tenderness over bilateral temporomandibular joints, limited jaw opening (32 mm)
• Neck: Restricted ROM in all planes, prominent trapezius and SCM trigger points
• Musculoskeletal: Widespread tenderness at all 18 classic tender points (16/18 positive), no joint swelling or erythema, full ROM in major joints but pain at end range, multiple myofascial trigger points in trapezius, rhomboids, piriformis, and gluteus medius
• Neurological: Normal strength 5/5 throughout, intact sensation, DTRs 2+ symmetric, allodynia to light touch over upper trapezius bilaterally
• Psychiatric: Flat affect, tearful when discussing impact on parenting, endorses frustration and hopelessness about condition

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Polysomnography: Reduced N3 (deep) sleep to 4% of total sleep time (normal > 15%), alpha-wave intrusion into delta sleep (alpha-delta sleep anomaly), AHI 2.1 (no significant sleep apnea), PLM index 8
• MRI cervical spine: Mild degenerative changes at C5-C6 without neural compression
• Quantitative sensory testing: Lowered pressure pain thresholds diffusely, temporal summation present (wind-up), impaired conditioned pain modulation
• ACE score: 4/10 (significant adverse childhood experiences)
• Fibromyalgia Impact Questionnaire (FIQ): 72/100 (severe impact)
• Central Sensitization Inventory: 58/100 (above 40 indicates central sensitization)

Clinical Image

Illustration of central sensitization mechanisms in fibromyalgia showing amplified pain signaling in the dorsal horn, descending inhibitory pathway dysfunction, neuroglial activation, and the overlap between fibromyalgia, chronic fatigue, and TMJ dysfunction. Source: Educational illustration.

Diagnosis

Fibromyalgia with Central Sensitization, Alpha-Delta Sleep Anomaly, Vitamin D Deficiency, Magnesium Deficiency, and Early Insulin Resistance

Key Diagnostic Criteria:

• 2016 Modified ACR criteria met: Widespread Pain Index (WPI) 14/19, Symptom Severity Scale (SSS) 10/12, symptoms present > 3 months
• Central sensitization confirmed by quantitative sensory testing (temporal summation, impaired conditioned pain modulation)
• Alpha-delta sleep anomaly on polysomnography explaining unrefreshing sleep
• Normal inflammatory and autoimmune markers excluding systemic rheumatic disease
• Significant micronutrient deficiencies (vitamin D, magnesium) and emerging metabolic dysfunction (fasting hyperinsulinemia)

Treatment Plan

1. Pharmacological optimization: Increase duloxetine to 90 mg daily (if tolerated), add low-dose naltrexone (LDN) starting at 1.5 mg at bedtime titrating to 4.5 mg over 4 weeks for neuroinflammation modulation, discontinue daily ibuprofen (peripheral analgesics minimally effective in central pain)
2. Sleep restoration: Trazodone 50 mg at bedtime for N3 sleep enhancement, strict sleep hygiene protocol, weighted blanket trial, evening magnesium glycinate 400 mg
3. Nutritional correction: Vitamin D3 50,000 IU weekly for 8 weeks then 5,000 IU daily maintenance, magnesium glycinate 400 mg BID, anti-inflammatory dietary pattern (Mediterranean diet focus), reduce refined carbohydrates to address insulin resistance
4. Movement therapy: Aquatic therapy 2x/week (warm water pool), tai chi program 2x/week (evidence-based for fibromyalgia), graduated walking program with pacing strategy
5. Pain neuroscience education: Structured 4-session program explaining central sensitization, neuroplasticity of pain, and the distinction between hurt and harm
6. Trauma-informed care: Referral for somatic experiencing therapy given ACE score of 4 and trauma history, mindfulness-based stress reduction (MBSR) 8-week program
7. Myofascial therapy: Trigger point dry needling for trapezius, piriformis, and gluteus medius, self-myofascial release instruction with foam roller
8. Follow-up: FIQ reassessment at 8 and 16 weeks, sleep study follow-up at 12 weeks, metabolic panel and insulin at 12 weeks, vitamin D and magnesium levels at 8 weeks

Key Learning Points

• Fibromyalgia is a central sensitization syndrome with demonstrable neurobiological abnormalities including altered pain processing, neuroglial activation, and disrupted descending inhibition, not a diagnosis of exclusion
• Alpha-delta sleep anomaly (alpha wave intrusion into N3 sleep) is found in up to 80% of fibromyalgia patients and is a key driver of symptom severity; addressing sleep architecture is critical
• Low-dose naltrexone (LDN) modulates neuroinflammation via toll-like receptor 4 antagonism on microglia and has growing evidence in fibromyalgia with minimal side effects
• Adverse childhood experiences (ACEs) are significantly associated with fibromyalgia risk through persistent HPA axis and autonomic nervous system dysregulation; trauma-informed care should be integrated
• Multimodal treatment combining pharmacology, movement therapy, pain neuroscience education, and psychosocial interventions consistently outperforms any single-modality approach in fibromyalgia

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