Reprinted with the kind permission of Cort Johnson and Health Rising
Naturopath and nutritionist, Dr. David Brady, has taken a kind of media driven, rock-star approach to alternative health. He’s got the flashy website; he’s written the book with the catchy title, The Fibro Fix: Get to the Root of Your Fibromyalgia and Start Reversing Your Chronic Pain and Fatigue in 21 Days; he’s doing interviews all over the place; he’s got his own brand of supplements; he’s a “Doctor Oz” expert (!); he hosted an online “Fibro-Fix Summit;” he’s doing podcasts — the man is out there promoting his stuff.
His website’s claim that Brady has published in “leading peer-reviewed medical journals” is pretty sketchy, though, with few publications listed on PubMed. Brady has, however, contributed several review articles to alternative health and other journals not listed on PubMed and is a contributing author to several integrative health textbooks. He’s also Chief Medical Officer of his diagnostic lab. In short, he’s a busy man.
He’s got a message. If you think you have FM, you probably don’t. Your doctor may have told you that you have fibromyalgia, but the odds are that Dr. David Brady would probably disagree.
Most people, Brady rather audaciously proclaims, who think they have fibromyalgia (FM) have what he calls “Pseudo-FM.” Don’t feel badly, though, if you’re in that group: according to Brady, you have a lot better chance of healing if you are. In fact, one of the best signs that you didn’t have what Brady calls “Classic FM” is if you’ve been cured of whatever you have.
First, though, let’s look at an unusual aspect of Brady’s approach – his belief that FM is a psychosomatic disorder which presents with a distinct personality profile.
The Psychosomatic Naturopath
Brady’s a naturopath and functional medicine doctor, but psychology and trauma are important factors for him. Brady doesn’t mention his psychosomatic leanings much in FibroFix but is clear about them in his review papers, calling “classic FM” a “bonafide psychosomatic” disorder caused by persistent hypervigilance and over-activated limbic system pathways, and likening it to a mental illness.
In another paper and in his book he states that:
“these classic cases probably represent the somatic manifestations of extreme emotional stress and/or psychologic illness, yet are distinct from a true somatization disorder in which there is no real physical illness.”
He’s certainly not alone. The idea that fibromyalgia is a kind of psychosomatic disorder, triggered by physical, emotional or sexual abuse, has a long history in research. A 2017 review, “The management of fibromyalgia from a psychosomatic perspective: an overview” emphasized the importance of considering and treating the comorbidity of FM with psychiatric disorders and psychological factors that affect pain management.
Recent studies have found higher rates of “psychosomatic syndromes,” PTSD, anxiety and depression in FM patients than in rheumatoid arthritis (RA) patients. Yet the story may not be so clear-cut. The fact that FM patients appeared to be in considerably more pain than RA patients suggested they were under more stress. (Remarkably, the study used different pain measures for the two groups and didn’t investigate whether pain levels affected the rates of anxiety, depression, etc.) Plus, the rate of possible “psychosomatic syndromes” was almost as high in RA (79%) as in FM (100%) – suggesting that FM doesn’t have anything like a lock on “psychosomatism” in rheumatological diseases.
Brady even uses psychological factors at times to help separate chronic fatigue syndrome (ME/CFS) from fibromyalgia patients; people with FM have them and people with ME/CFS apparently don’t. (Who knew??)
“Well, if the condition seemed to come on historically after a viral type illness, and the main complaint is fatigue, and there’s not a significant body wide pain, body wide achiness component, and, particularly, if there’s none of those other central, psychological type of issues like depression, anxiety, panic attack, then you’re not dealing with classic…fibromyalgia.”
Brady’s attempt to back up his interpretation of FM as a kind of psychological illness isn’t particularly convincing. He uses the fact that antidepressants often work “well,” at least in the short term, in FM, as evidence for the important role psychological factors play in the illness, yet ignores the fact that some of those same antidepressants reduce pain in FM patients who are not depressed; i.e. they’re often working as pain relievers, not antidepressants.
Early Life Trauma
“Our best guess is that it (fibromyalgia) usually originates early in life due to emotional or physical stress or trauma.” Dr. Brady
Early life trauma plays a major role in Brady’s conception of FM. Brady agrees that not everyone with FM experiences it, but states that it’s common and repeatedly refers to it. (All of the patient examples of classic FM in Brady’s FibroFix book had some sort of early-life trauma.) He repeatedly cites a 600-person study which found higher rates of emotional, physical or sexual trauma were associated with FM onset.
The “aha” moment for Brady with one patient, for instance, came when he’d discovered she’d been in an automobile accident which killed her brother. Brady stated:
“And usually there is often sort of a history, when you really talk to these patients, of kind of a difficult or tumultuous early life. It could be abuse. It could be physical abuse. It could be verbal abuse. It could be sexual abuse. That’s the most damaging.”
But it could just be being in an unsafe environment or an environment that was never steady, like moving all the time; being a child of divorce; an acrimonious relationship between mother and father; a very authoritative, demanding parent, particularly a father figure to a young girl where she could never feel she would measure up, never be good enough no matter how well she did.”
After asking about a person’s pain, Brady gives patients his own child abuse quiz:
“What was your upbringing like? What was your childhood like? What was your relationship like with your parents? Your siblings? Did anyone else live in your household? Grandparents, aunts, uncles? What was the relationship like with them? Was there any abuse going on? Was there any loud yelling? Was there alcoholic … Raging alcoholic dad for instance?”
It’s pretty clear that early life abuse can set the stage for chronic pain later on. A recent review article, Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms, laid out a number of physiological pathways (the hypothalamic-pituitary-adrenal axis; monoaminergic, opioidergic, endocannabinoid and immune systems; and epigenetic mechanisms) that studies suggest could contribute to that.
The study evidence regarding fibromyalgia is less clear, however, than Brady makes it out to be. One study found that 65% of women with FM patients experienced sexual abuse but so did over 50% of the healthy controls. Another found that 37% of FM patients and 22% of healthy controls had experienced childhood abuse. A third found no evidence that rates of childhood sexual or physical abuse were higher in FM than in rheumatoid arthritis (emotional neglect was).
Brain Wallitt’s study found a “clinically modest, yet statistically significant” effect of physical abuse on the amount of pain experienced in FM. The effect was so modest, though, that the authors stated that, “Group differences are of small magnitude and might not directly impact clinical practice;” i.e. it appears they hardly affected pain levels at all.
Another study found that several of the associations between early life trauma and FM disappeared when depression was taken into account; i.e. FM patients without depression did not have an increased incidence of physical abuse and emotional neglect. Another study found no evidence of increased sexual or physical abuse in FM.
Two meta-analysis studies, however, confirmed the link between childhood trauma and “functional somatic syndromes” such as FM, IBS, TMJ, ME/CFS, etc. Individuals with some sort of childhood trauma were 2.7 times more likely to come down with one of these disorders. Study quality, however, was generally poor and one meta-analysis found that the poorer the quality of the study, the greater association that appeared between FM and childhood trauma.
One of Many Diseases
FM is not alone; early life stress is associated with an increased risk of rheumatoid arthritis, multiple sclerosis (odds ratio – 2.0-3.4; similar to FM), autoimmune diseases in general, hypertension, asthma, cardiovascular risk, arterial stiffness — the list goes on and on.
Despite Brady’s emphasis on early life stress in FM, it’s possible there’s nothing particularly special about the rates of childhood abuse in the disease. A history of childhood abuse is associated with a 25-50% increased risk of diabetes, a 45% increased risk of heart disease, a 50% increased risk of arthritis (50% increased risk).
Migraine presents an interesting study in the importance of sexual abuse and disease. Migraine, like FM, is a pain disorder which largely affects women. One study indicated that 47 percent of migraine patients had been victims of physical or sexual violence compared with 36 percent of young women without migraine. So yes, migraine was associated with an increased risk of childhood trauma, but only to a degree. The study concluded that abuse increased one’s risk of coming down with migraine by about 40%.
Missing Risk Factors
In his focus on psychological factors, Brady also misses other kinds of trauma that can increase one’s risk of pain sensitization. Much evidence, for instance, suggests that premature birth can, through its effects on the HPA axis, result in increased pain sensitization. Surgery or burns during childhood can set up a similar pain sensitization process. Having another pain disorder has the same effect; it appears that any kind of trauma or injury puts one at least at some increased risk of coming down with FM or a similar pain condition.
The problem is not that Brady links childhood trauma to FM; the problem is the central role Brady gives the factor. It appears to be the only risk factor Brady is contemplating and that’s too simplistic.
Brady’s Fibromyalgia Personality Profile
Brady’s gut-level assessments of “the fibromyalgia personality” are embarrassingly naïve. No one has the ability to assess personalities anecdotally and Brady’s pop psychology is not convincing.
“These people tend to be overachievers, very fastidious. They like to be in control of everything and in their environment. So therefore, they are high achievers. But they never feel they can meet the mark. Now, that’s not in every classic fibromyalgia patient. But it’s really, really much higher in their history than people who don’t have fibromyalgia.”
“They’re (the classic FM patients) always in defensive posture if you will. So they tend to have personalities that align with that. They tend to be always worrywarts about everyone around them, they’re very much caretakers, they’re worried about their kids, their spouse, if something bad is going to happen to them, how do I take care of them? And they’re all about facilitating and protecting everyone else and they don’t take care of themselves essentially. And eventually it all comes crashing down.”
“But that’s why they have anxiety and panic. They’re always waiting for the worst to happen. They tend to be very fastidious and very neat. They need everything in its place, they want order, they hate chaos.”
The problem is that it’s very easy to find components like this in many of us. Authoritative parents, divorces, acrimonious relationships are common, neat-niks, caregiver personalities are common throughout the population. Brady’s FM personality, in fact, hews very close to the debunked migraine personality – of high-strung, perfectionist, anxious women – which dominated the migraine field for years and set migraine research back decades.
The study evidence does not bear out Brady’s intuitions. Two 2012 studies found that perfectionism is not elevated in FM nor does a personality profile distinct to FM exist.
If you have classic FM, you’ve got a brain injury – never something easy to treat. Central sensitization is causing your nervous system to treat all sorts of ordinary sensations as pain and you’re fatigued. Your overloaded nervous system may be having problems with high-stimuli environments, leaving you feeling overwhelmed in malls, large stores, freeways, etc.
Cognitively you’re slower than before and your concentration has suffered. With all the brain circuits that are tottering, it’s perhaps no surprise that depression and anxiety are common. Plus, you’re not sleeping well. You may be able to do some exercise but heavy exercise is definitely out.
You might respond pretty well to low-dose levels of anti-depressant or anxiety medications or biofeedback or behavioral techniques designed to lower your stress levels. You’re also fairly rare: Brady believes probably 2/3rds of people diagnosed with FM don’t have it.
Brady’s “Total Treatment” Program for “Classic” Fibromyalgia
So you have “classic FM.” Congratulations on getting a diagnosis, but the news is actually not so great – calming down your central sensitization is going to take some doing.
Brady believes that mood disorders and FM have similar causes (serotonin issues, micro-inflammation of the brain and a history of stress, trauma or abuse). Stress causes inflammation, which contributes over time to development of mood disorders and ultimately to more complex disorders such as FM and IBS.
His goal appears to be to remove inflammatory influences via diet, supplements and stress reduction practices, and to reinforce the nervous system functioning enough for it to recover. Brain inflammation is addressed via dietary changes, supplements, botanicals, lifestyle modifications, GI flora optimization, alleviating leaky gut and drugs.
Serotonin and substance P play critical roles in Brady’s conception of the pain sensitization and irritable bowel issues occurring in FM. He uses supplements (5-HTP (50-100mgs with meals), St John’s Wort (300 mgs/3x’s day), SAMe (1,600 mgs/day), melatonin (3-9 mgs), phophatidylserine (50-100 mgs/day), L-theanine (1-200 mgs/day), GABA (1-200 mgs/2-3x’s day) and calming botanicals (Valeriana, Passiflora, Scutellaria, MelissaI) to boost serotonin, support the adrenals, and provide mood support.
(Brady sells different packages of supplements (Fibro-Fix Classic, Sero-tone, Neuro-Fx and FibroMag) on his website.)
Exercise – greatly modified exercise – is important. Brady wants his FM patients to slowly and gently get to 10,000 steps a day. Ten thousand steps sound like a lot, but it’s simply what most people walk in a day – it’s not an indication of a cure.
Brady also strongly encourages forms of gentle movement, relaxation and stress reduction such as “counseling, desensitization techniques, forgiveness therapy, guided imagery, heart-rate variability training, meditation, progressive muscle relaxation, Tai chi, yoga.”
Supplements and drugs are only going to take you so far biochemically though. What’s really needed is some brain work. Cognitive behavioral therapy, brain mapping, and EEG directed biofeedback are used to train FM patients to get their brains into calming states – a “super important” thing to do.
Phone apps can use heart rate variability measures to help one induce states of calm. Meditation, yoga, desensitization techniques, guided imagery, progressive muscle relaxation, forgiveness therapy, prayer; anything that resets one’s stress meter is very important.
There’s certainly nothing wrong with using behavioral techniques to treat pain. Pain itself increases the risk of being diagnosed with anxiety, depression and having negative anticipations and catastrophic thinking. Every one of these factors increases pain levels. Calming techniques and mindfulness meditation are used effectively to reduce pain levels, as well the consumption of opioid drugs in many pain conditions.
Brady mostly eschews the FDA approved drugs for FM: sleep medications and antidepressants. Low dose naltrexone (LDN) is mentioned briefly but, as of the writing of Fibro-Fix, did not appear to be part of his treatment protocol. Medical marijuana – possibly the most effective pain reliever of them all in FM – is not mentioned.
Sleep hygiene, of course, is important. No blue lights (no iPad or laptops unless they have a blue light filter) are allowed after about seven to eight o’clock at night. Wakeup time is 7:00, 7:30 in the morning.
Exercise, starting with increasing flexibility and range of motion, is important as well.
Aside from more of an emphasis on stress reduction, Brady’s program is similar to that of other alternative health doctors. Brady reported of one classic FM patient, “Jennifer,” who suffered from global pain, who had a history of anxiety and depression, a verbally abusive father and normal blood tests, including thyroid.
Jennifer’s clear indicators of FM (to Brady – past history of trauma, sleeplessness, anxiety, depression and IBS) suggested she had “classic FM.” She was put on Brady’s 21-day Fibro-Fix Foundational Plan plus 5-HTP, melatonin, GABA, calming herbals and nutrients, CoQ10, mild stretching and exercise, daily meditation and psychological counseling.
Pseudo FM: the Alternate Diagnoses
The most singular thing about Brady’s book and approach is his emphasis on the prevalence of misdiagnosis in FM. Brady believes that misdiagnosing FM is so common that about 75% of FM patients don’t really have it but have another disease that can probably be treated.
- Anemia: take complete blood counts – check for low RBC, altered hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin.
- Erythrocyte sedimentation rate / C-reactive protein test: check for systemic inflammation or infection.
Brady believes a common mistake is not finding a musculoskeletal condition. Brady believes that about 20-30% experiencing global pain have a musculoskeletal problem, not FM.
During his examination, Brady is “looking for things like muscle tightness, muscle spasms, trigger points of myofascial pain syndrome…if they have a lot of that where they’re complaining of pain, then I’m thinking ‘Wait. This might be a structural, musculoskeletal issue, not a pain perception issue’,” particularly if they’re not anxious, depressed, and have IBS.
If your pain is in your soft tissues and you mostly experience muscle pain, then Brady believes you probably have FM, but if it’s in your joints, you probably have some sort of inflammatory arthritic condition such as rheumatoid arthritis. If you do indeed seem to hurt everywhere but also suffered some injuries in the past that could account for that, you probably don’t have FM, even if you’ve been treated for those injuries.
Another way to tell if “classic FM” is present: if physical therapy such as physical medicine, PT, chiropractic, massage, body work, produced a lasting effect, the patient didn’t have classic fibromyalgia: they had myofascial pain syndrome or some other musculoskeletal problem.
Spinal Facet and Sacroiliac Pain can emanate far past the aggrieved facets, but unfortunately MRI, x-rays and bone scans are of no help in diagnosing this condition. Unfortunately, other than stating that this difficult-to-diagnose condition exists, Davis provides no help in how to diagnose it.
Missed Evidence of Structural Damage
Brady is entirely correct that x-rays and MRIs do poorly in assessing the causes of chronic pain, but it’s probably far more common for doctors to misinterpret scans in the other direction and over diagnose structural damage leading to needless surgeries and more pain. In FibroFix, Brady points out that he’s come across people with misalignments, postural problems, tendonitis, pinched and disc degeneration who have been misdiagnosed as having FM. (Oddly enough, I found no mention of chiari malformation.)
Myofascial Pain – Trigger Points are commonly missed. These ropey lumps or knots in the muscles often found in FM are distinct from tender points. They’ll respond to massage and other kinds of physical therapy (while tender points will not).
Besides gentle stretching and exercise (Brady has a nice section on stretching), Brady uses supplements (proteolytic enzymes, bioflavinoids, turmeric, ginger, boswellia and EPA) to reduce inflammation associated with musculoskeletal issues. Calming herbs are also used.
Brady acknowledges the high degree of professionalism of most physical therapists, but mostly eschews PT approaches focused on strengthening and increasing mobility in favor of practitioners who know how to do myofascial therapy. For those delving into the world of soft-tissue work, Brady recommends practitioners using Active-Release Technique, Graston Technique, Receptor-Tonus training, St. John’s Technique and/or myofascial release. As does Dr. Liptan, Brady highly recommends light massages (aka Swedish).
- Hypothyroid – Hypothyroidism is probably the mostly commonly missed diagnosis. Besides fatigue, weakness, cold intolerance and depression, Brady points out that low thyroid can also produce muscle stiffness and pain, pins and needles sensations, muscle weakness and sluggish deep tendon reflexes. Thankfully, Brady delves to some extent into the complexity of thyroid diagnostics with a warning that standard thyroid tests may not sufficient. His book, FibroFix, has an excellent overview of the topic.
- Adrenal dysfunction – Morning serum cortisol and urinary catecholamine metabolites can be useful in assessing adrenal dysfunction. (Brady is compelled to note that low cortisol and high catecholamine levels are found in PTSD.) The treatment? Psychological counseling and stress-reducing lifestyle modifications.
- Mitochondrial Problems – organic acid tests are done to check these.
Brady doesn’t mention other misdiagnoses, including some that are surprising for a functional doctor. They include mast cell activation syndrome (MAST), Ehlers Danlos Syndrome (EDS), postural orthostatic tachycardia syndrome (POTS), mold issues, restless leg syndrome, polymyalgia rheumatica, hyperparathyroidism, Sjogren’s Syndrome, gluten intolerance, lupus, early onset multiple sclerosis, sleep apnea or other sleep disorders, and prescription drug use.
It Takes A Functional Doctor
Brady may be right about one thing: FM is probably harder to treat than other so-called “functional disorders” which often appear to show up as fatigue, pain, or sleep issues but without an overt pathology. Brady’s experience indicates to him that “many functional issues require only simple lifestyle changes.” If you have gut problems, there are supplements and dietary changes that can fix that; ditto with cellular energy production.
Brady’s approach is relatively simple but he does present some compelling cases of “pseudo-fibromyalgia” he was able to resolve.
One of his cues that a patient doesn’t have FM concerns drugs or treatments that don’t work. Donna’s inability, for instance, to improve her symptoms (fatigue, pain, insomnia) on antidepressants and Ambien gave Brady an important clue that she didn’t have FM at all.
A workup indicated low normal thyroid markers, inefficiencies in energy production and detoxification, and low serotonin metabolites. Donna went on Brady’s 21-day Fibro-Fix plan plus CoQ10, L-carnitine, D-ribose and B-complex vitamins, Nature Thyroid and 5-HTP. Within 30 days, Brady reported that she was much improved and 60 days later was completely well.
The next patient story (Christine) exhibited problems with energy production, and like Donna, was put on the Fibro-Fix Foundational plan plus CoQ10, L-carnitine, D-ribose and B-complex vitamins and probiotics. Within 60 days, her symptoms were 90% gone as well.
Of course, if it was that simple, many of you wouldn’t be reading this blog. Brady doesn’t present much help for harder cases who’ve already tried and failed on the alternative medicine circuit, but for those new to alternative medicine, his book presents real possibilities.
Brady’s focus on early life trauma is surely over-stated and his fibromyalgia personality profile should be ditched as soon as possible. Early life trauma does set the stage for some FM patients, but there’s little evidence that it’s that much more of a contributor to FM than it is to other diseases.
Others will know better than me how effective they are, but Brady’s suggestions for overcoming FM and other health problems mostly make sense to me. At times his conclusions (“just adopting an organic food diet – ideally free of processed grains, gluten-containing grains and dairy) – is generally life-changing for those suffering with pain and fatigue disorders” made me – a longtime ME/CFS/FM sufferer (with an excellent diet) made me cringe. Brady does, on the other hand, offer quite a few options for those with classic FM and other diseases.
Brady’s concern that his patients take a “package approach” to the disease – that is, embark on a multi-faceted program which includes dietary changes, supplements and herbs, physical therapy, perhaps some drugs plus stress reduction – makes sense.
One has to question, though, just who gets “fixed” using Brady’s approach. (People with less severe cases of FM?) Brady’s protocol surely does help many, but fixing fibromyalgia probably happens more rarely than his book title suggests. In this regard, Dr. Liptan’s approach in Figuring out Fibromyalgia, where she simply claims to offer the most effective treatments, is the more honest one. Still, Brady’s FibroFix book surely provides helpful options for many who are not up on functional medicine.
Given the book’s emphasis on misdiagnoses, it’s surprising how many alternate diagnoses Brady missed in his 2016 book. His distinction between “classic” and “pseudo” fibromyalgia should alert doctors and other practitioners to the missed diagnoses that may very well permeate the field and cause much suffering.