Hair Calcium and Magnesium Levels in Patients With Fibromyalgia: A Case Center Study

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Hair Calcium and Magnesium Levels in Patients With Fibromyalgia: A Case Center Study

ABSTRACT

Background: Fibromyalgia is not an uncommon condition. Because its cause has yet to be identified, treatment of the condition has been empirical; frequently, outcomes are unsatisfactory. Some patients with fibromyalgia were observed to have high hair calcium and magnesium levels compared with healthy subjects. Because of this and because supplementing calcium with magnesium to fibromyalgia subjects reduced the number of tender points detected by digital palpation, it is worth investigating if patients with fibromyalgia have significantly higher hair calcium and magnesium levels than their healthy counterparts.

Objectives: To determine the degree of difference between the hair calcium and magnesium levels in patients with fibromyalgia and in healthy subjects.

Methods: The study was retrospective and of paired design. Twelve patients who had hair analysis performed and met the criteria of fibromyalgia defined by America College of Rheumatology (1990) were selected consecutively from clinical files. These patients were then matched by age and sex to 12 healthy subjects selected consecutively from the same patient files who had hair analysis performed for checkup purposes. Nonparametric Wilcoxon rank sum tests were used to determine if the hair calcium and magnesium levels in patients with fibromyalgia were significantly higher than that of the control subjects.

Results: Wilcoxon rank sum tests showed that patients with fibromyalgia had significantly higher calcium and magnesium levels than the control subjects at à = .025 and .05, respectively.

Conclusion: In the presence of high hair calcium and magnesium levels, calcium and magnesium supplements may be indicated as an adjunctive treatment of fibromyalgia, (J Manipulative Physiol Ther 1999;22:586-93)

Key Indexing Terms: Fibromyalgia; Calcium; Magnesium

INTRODUCTION

Fibromyalgia is a common rheumatic disorder with no known cause that affects mainly middle-aged women.( 1) There are a number of different treatments for this condition, including muscle strengthening, aerobic exercises, electroacupuncture,( 2) electromyographic biofeedback,( 3) tricyclic antidepressants, S-adenosyl methionine,( 4) thiamin, vitamin B( 6),( 5) calcium antagonists,( 6) and magnesium supplements.( 7) The outcome of these treatments varies.

Reviewing hair analysis reports of patients with fibromyalgia, I found that the hair calcium and magnesium levels of some are high compared with those of other patients and healthy subjects. In addition, because supplementation of calcium and magnesium to some patients with fibromyalgia was found to reduce the number of tender points detected by digital palpation, I theorize that calcium and magnesium may have a role in the condition.

This study attempts to examine the relevance of hair analysis in fibromyalgia. Hair calcium and magnesium levels in patients with fibromyalgia and sex- and age-matched healthy controls are determined by hair analysis. The differences in hair calcium and magnesium levels in patients with fibromyalgia and healthy subjects was then determined to test if patients with fibromyalgia have significantly higher hair calcium and magnesium levels than healthy subjects with significance set at à = .05.

The null hypothesis was that the hair calcium and magnesium levels of women with fibromyalgia and patients with primary fibromyalgia are the same as that of healthy female subjects and healthy subjects as a group. The alternate hypothesis was that hair calcium and magnesium levels in female patients with primary fibromyalgia and patients with fibromyalgia are significantly higher than healthy female subjects and healthy subjects as a group.

METHODS

Sample Size

This was a retrospective study, involving the comparison of hair calcium and magnesium in patients with fibromyalgia (group 1) and healthy subjects (group 2).

The sample size was determined by power analysis for l-tailed test at à = .05 and power level of 0.7. To estimate the sample size required, patients with fibromyalgia were assumed to have an average of 1000 ægg(-1) more hair calcium than the control subjects. The standard deviation (SD) of hair calcium was assumed to be 600 ægg(-1), based on the results of a previous study.( 8) The sample size was also determined, assuming a 40 ægg(-1) difference in hair magnesium between the 2 groups and an SD of 20 ægg(-1). The number of sample size determined by the above 2 methods was then compared, and the larger number was used as the sample size of this study. The analysis showed that a minimum of 12 subjects for each group was required for the study.

Patient Selection and Selection Criteria

Convenience sampling of subjects was used. Patients with fibromyalgia and healthy controls were selected from a private chiropractic clinic where patient records were stored in databases. The diagnosis of fibromyalgia was used to search patient files from January 2, 1996, to December 30, 1996. Out of 1105 patient files, 52 patients with fibromyalgia were identified.

Examination of the 52 patients' histories showed that 16 had hair analysis performed. These patients had widespread pain for a varying period, ranging from 9 months to more than 10 years. They had pain in 11 or more of the 18 tender point sites elicited by palpation with moderate digital pressure, which was not objectively quantified. The points were only regarded as tender when withdrawal from pressure or verbal response of pain were elicited. Fourteen of the patients had tender points identified in the suboccipital area, at the anterior aspects of the intertransverse spaces at C5-7, at the mid-point of the upper border of trapezius, at the medial aspect of the supraspinatus, at the second costochondral junctions, in the anterior border of the gluteus medius, the greater trochanter, and the medial knees bilaterally. The other 2 patients had identical tender point spots on the medial knees. Other associated symptoms that the patients had included hyposomnia, subjective swelling of the hands, and tiredness. Thus 16 patients met the American College of Rheumatology 1990 criteria( 9) for fibromyalgia and had hair analysis.

To ensure that the patients were homogeneous, patients with possible secondary fibromyalgia were excluded. Radiographs and blood tests of the 16 patients were reviewed. One subject was found to have a marked spinal scoliosis. She was excluded from the study because abnormal spinal curvature may cause pain syndromes that are similar to fibromyalgia. Also excluded from the study was a woman with hypothyroidism. This left 14 patients with fibromyalgia; they had no clinical evidence or laboratory findings to suggest rheumatoid arthritis, hypothyroidism, muscle diseases, or other disorders. Before the hair analysis, the questionnaire the patients completed was reviewed. Two patients had permed hair; because hair treatments may affect hair calcium and magnesium levels,( 10) they were likewise excluded from the study. This left 12 patients for the study, 9 women and 3 men. The women included in the study were aged 33 to 58 years, with an average age of 44.6 years and a median age of 44 years. The male patients had an average age of 36.3 years.

The patients selected for the study were then matched by age and sex to healthy subjects. Twelve subjects were selected consecutively from the clinic's files. To qualify for inclusion, they had to have no known symptoms or signs to suggest systemic disease. All control subjects had only a history of repetitive injuries or ankle sprain and had hair analysis performed for screening purpose. The age of the female control subjects ranged from 33 to 57 years, with an average age of 44.6 years and a median age of 44 years. The average age of male control subjects was 37.3 years.

The matching of age and sex of patient group and the healthy control group was necessary because both sex( 10) and age( 11) were found to influence hair calcium and magnesium concentrations. Matching of race and hair color, which similarly affect hair elemental levels, was not performed because all the subjects studied were Chinese and had black hair.

Hair Analysis

Before sampIing of the hair, each subject completed a questionnaire, which contained signs, symptoms, and the types of hair treatments.

Preparation of hair samples of the subjects was standardized. The hair of all the subjects was cut from the scalp in the occipital area with stainless steel scissors. Only the proximal 5 cm of the hair were used because proximal hair growth is more representative of the body's recent elemental status and is less likely to be contaminated. The cut hair was put into a plastic lock bag and was sent to Biochemical Laboratory in Noriarty, New Mexico, for analysis. Results of hair calcium and magnesium levels expressed in ægg(-1) were then used for statistical calculation.

Design

The study was a retrospective survey. Pair design was used. Patients with fibromyalgia and healthy subjects were matched by age and sex. The hair calcium and magnesium levels of patients with fibromyalgia (group 1) were compared with healthy controls (group 2) to determine if the hair calcium and magnesium levels were significantly higher in patients with fibromyalgia than their counterparts in healthy controls.

Statistical Analysis

Nonparametric statistical tests were used because of the small number of sample subjects and because normal distribution of the hair calcium and magnesium could not be assumed. Wilcoxon rank sum test was used to determine if hair calcium and magnesium levels in female patients, male patients, and in group 1 were significantly higher than that of the respective counterparts in group 2.

RESULTS

Hair Calcium and Magnesium Levels

The hair calcium level in group 1 was detailed in Table 1. The hair calcium and magnesium levels of female patients in this group (Table 2) were higher than that of their male counterparts (Table 3). The hair calcium level of the healthy control subjects was lower (Table 1). The hair calcium and magnesium levels in female control subjects were higher than that of the respective men (Tables 2 and 3).

Difference between Hair Calcium and Magnesium Levels in Patients with Fibromyalgia and Healthy Controls

Wilcoxon rank-sum test showed that hair calcium and magnesium levels of female patients in group 1 and group 1 patients were significantly higher than that of their respective counterparts in group 2. For female patients in group 1 and group 2, the Student t statistic calculated for ranks was 3.0. This is greater than 2.921, the l-tailed critical value of t for 16 degrees of freedom for à = .005. Regarding the difference between hair calcium levels of group 1 and group 2 subjects, the t statistic calculated for ranks was 2.42. This is greater than 2.074, the 1-tailed critical value of t for 22 degrees of freedom for à = .025.

For hair magnesium levels, the t calculated for the women in group 1 and group 2 subjects was 1.96 (à = .05). The t calculated for group 1 and group 2 subjects was 2 (à = .05).

The results support the hypothesis that the hair calcium and magnesium levels of female patients with fibromyalgia and patients with fibromyalgia as a group are significantly higher than that of the female healthy controls and healthy subjects respectively.

DISCUSSION

Fibromyalgia was first described by Smythe.( 12) It is a syndrome characterized by chronic, diffuse pain, an absence of inflammatory or structural musculoskeletal abnormalities, and a range of symptoms including fatigue and sleep disturbances. There is no objective evidence for the condition except for the presence of pain on modest palpation of tender spots.

As a result of the lack of physical or psychologic pathologic conditions, there are critics of the concept of fibromyalgia as a specific condition.( 13) Nevertheless, its symptoms and signs are characteristic( 14) and can be classified. The most extensive study that was undertaken in classifying fibromyalgia was that performed by Wolfe et al.( 9) The study resulted in the 1990 American College of Rheumatology classification criteria, which showed that fibromyalgia can be differentiated from other rheumatic diseases with an accuracy of 85%.( 9) Thus fibromyalgia is a well-defined clinical syndrome.( 15)

Prevalence

In the general population, estimates of prevalence range from 0.75%( 16) to 10.5%,( 17) with most evidence for approximately 2%.( 18) The prevalence in medical and rheumatology centers is generally higher and has been reported at 5.7%( 19) and 20%,( 20) respectively.

The condition affects men, women, and children. Women are affected far more frequently than men.( 1, 16) Age of onset varies from 12 years( 21) to 64 years( 16) of age. In most reported cases, the mean age of those afflicted is 40( 14) to 50 years,( 22) with the prevalence in the elderly lower than that of the middle-aged group. This suggests that most of the patients eventually either get better or develop some other more specific disease to account for their symptoms.( 13)

Clinical Features

Patients have chronic generalized musculoskeletal pain. Depression generally antedates fibromyalgia by many years.( 23) The syndrome often begins with localized pain in the neck/shoulder area, low back, or hips/buttocks. The pain usually increases gradually over the years and spreads to, involve other parts of the body.( 24) In a retrospective study, Lapossy et al( 25) found that of 53 patients with chronic lowback pain, 25% of them developed fibromyalgia (only 1 male). The mean time for the progression was 18 years. Pathologic lordosis and scoliosis significantly increased the possibility of fibromyalgia developing.

Fibromyalgia is typically associated with persistent fatigue, nonrestoring sleep, and generalized stiffness.( 26) Associated symptoms or conditions that have been reported to accompany fibromyalgia include headaches,( 14) carpal tunnel syndrome? atypical patterns of numbness and tingling,( 28) atypical chest pain,( 29) dyspnea,( 30) irritable bowels( 31) female urethral syndrome,( 32) irritable bladder, dysmenorrhea,( 33) cold sensitivity, Raynaud's phenomenon,( 34) restless legs, subjective swelling in wrists and knees, fluid retention,( 35) exercise intolerance, and symptoms of weakness. A varying percentage (20% to 50%) of patients with fibromyalgia have significant depression or anxiety.( 14, 22) In most cases, the symptoms vary both diurnally and seasonally. Typically, symptoms are worse during periods of cold damp weather, at the beginning and end of the day, and during periods of emotional stress.( 1) Chronic fatigue, inactivity, and unaccustomed exertion( 26) also aggravate the symptoms.

Diagnosis

Criteria. For fibromyalgia, there is no abnormal laboratory test or pathognomonic clinical signs or symptoms. Diagnosis is clinical( 22) and depends on patient history, a careful physical examination, and findings that meet certain criteria. The latter, however, vary with different authors.( 9, 14, 36) Smythe and Moldofsky( 36) were the first authors to suggest criteria for the diagnosis of fibromyalgia. The criteria required the existence of generalized pain or stiffness, 5 tender points, and at least 3 minor symptoms. Yunus et al( 37) modified the criteria. They excluded skin roll tenderness, introduced by Smythe and Moldofsky,( 36) from the criteria and put less weight on the criterion of disturbed sleep. In 1989, they modified their earlier criteria and increased the number of anatomic sites expressing pain from 3 to 4, but reduced the number of tender points from 5 to 2. The minor criteria remained the same. In 1990, the American College of Rheumatology( 9) presented new diagnostic criteria (Table 4). Minor criteria or clinical symptoms other than widespread pain were no longer included. Also, other diseases with similar symptoms were excluded. Because the classification criteria have a sensitivity of 88.4%, a specificity of 81.1%, and an accuracy of 84.9%, they are quite specific for fibromyalgia and are commonly used for classification or diagnostic purposes. The criteria, however, may not be very sensitive in mild or early cases.( 22)

Thus for fibromyalgia, expert consensus opinion forms the standard of diagnosis.( 15) Patients with symptoms who met the criteria of the American College of Rheumatology (1990) are therefore regarded as having fibromyalgia, regardless of whether concomitant diseases are present.

Clinical Signs

Although there are no diagnostic tests of fibromyalgia, 5 objective clinical signs have been reported for the assessment of fibromyalgia. These include localized tender points,( 34) reduced pain threshold to pressure, increased skinfold tenderness, reactive tissue hyperemia, and decreased tissue compliance.( 38) The tender points are important objective features of primary fibromyalgia syndrome( 37); they are generally found in muscle or at muscle-tendon insertions with a predilection of the neck and shoulder girdle, pelvic girdle, and knee regions.( 39)

Management

Various treatments have been described for management of the condition. These include muscle strengthening, aerobic exercises, electroacupuncture,( 2) EMG biofeedback,( 3) amitriptyline, S-adenosyl methionine,( 4) thiamine, and vitamin B( 6),( 5) calcium antagonist,( 6) and magnesium supplementation.( 7) Abraham and Flechas( 7) showed that 300 to 600 mg of magnesium malate daily reduced the number and severity of tender points in patients with fibromyalgia. Eisinger et al( 4) concurred in the finding and suggested using magnesium supplements to treat the muscle weakness in fibromyalgia.

The average age of patients with fibromyalgia was 42 years. This agrees with the findings of Yunus et al( 14) and Jacobsen,( 22) who reported a mean age of 40 and 50 years, respectively.

In this study, there were 3 times as many women than men. The finding is in accord with previous reports that women are affected twice( 16) to some 10 to 20 times more often than men.( 1)

Hair Calcium Level

Healthy subjects. The hair calcium level of female subjects in group 2 was 1019.7 ñ 634.2 ægg(-1) (Table 2). This is slightly higher than the hair calcium level of 707 ñ 308 ægg(-1) reported in female subjects.( 40) The difference may be related to the age differences between the subjects. The average reported age of female subjects was 11.4 years, with a range of 7 to 15 years,( 40) whereas the average age of female subjects in group 2 was 44.6 years. Takagi et al( 11) showed that hair calcium levels increase with advancing age in Japanese women. The possibility of a small sample in this study may, however, contribute to the differences in the finding.

The hair calcium level in male subjects in group 2 was 326.3 ñ 126.8 ægg(-1). This agrees with the finding of 354.5 ñ 132.3 ægg(-1) in male Japanese children.( 40)

The hair calcium level in group 2 subjects as a whole was 846 ñ 645.7 ægg(-1). The findings fall within the range of hair calcium previously reported.( 8, 11) Shrestha and Schrauzer( 8) found a hair calcium level of 926 ñ 354 ægg(-1) in subjects in Darjeeling, India, and 783 ñ 464 ægg(-1) in subjects in San Diego, Calif. Takagi et al( 11) reported a mean hair calcium level varying from 452 ppm in samples from Canada to 1139 ppm in samples from Poland. The high SD of hair calcium level in group 2 subjects was possibly a result of our grouping the male and female subjects in the calculation. Male and female subjects had very different hair calcium levels. Also, the small number of subjects used in the study made the SD sensitive to extreme measurements. A wide variation of hair calcium in normal subjects may also contribute. The SD of hair calcium in subjects in San Diego( 8) was also relatively high, at 59% of the mean and that reported by DeAntonio was 108% of the mean.( 41) Nevertheless, because a number of variables such as sex, age, and hair treatments were not controlled in these studies, the large SD is not unexpected.

Patients with fibromyalgia. The hair calcium level of subjects with fibromyalgia is much higher. The hair calcium level in female patients is 2849.2 ñ 1933.9 ægg(-1) (Table 2). The high SD can be a result of a small sample size. It is possible that patients with different severity and chronicity of complaints have vastly different hair calcium levels, thus contributing to the high SD.

The hair calcium level in male patients in group 1 is 606 ñ 236.6 ægg(-1), higher than that reported in the literature for normal male children.( 40)

Overall, the hair calcium level of male and female patients in group 1 was 2288.4 ñ 1486.2 ægg(-1). Again, the finding is higher than those previously reported.( 8, 11, 42) The SD was high. This may be related to the wide variation in hair calcium level in female patients with fibromyalgia.

Hair Magnesium Level

Healthy subjects. The hair magnesium level in female subjects in group 2 was 55.1 ñ 39.4 ægg(-1) and that of the male subjects was 21.7 ñ 5.5 ægg(-1). The findings fall within the range of hair magnesium levels reported by Morita et al.( 40) They found a hair magnesium level of 72.46 ñ 52.6 ægg(-1) and 32.63 ñ 112.68 ægg(-1) in female and male Japanese children, respectively.

The hair magnesium of healthy control subjects was 46.8 ñ 28.9 ægg(-1). This is in accord with the findings by one study( 11) but is lower than that reported by others( 8) who reported hair magnesium level of 186 ñ 98 ægg(-1) for Indian subjects and 189 ñ 192 ægg(-1) for American subjects.

Patients with fibromyalgia. The hair magnesium levels of female and male patients with fibromyalgia (Table 2) are slightly higher than that reported by Morita et al.( 40) The hair magnesium of group 1 as a whole was 84.7 ñ 73.3 ægg(-1), falling between the hair magnesium values reported for Polish and Japanese subjects.( 11)

Comparison of Hair Calcium and Magnesium Levels in Patients with Fibromyalgia and Healthy Subjects

Results showed that hair calcium and magnesium levels in female patients with fibromyalgia are significantly higher than that in female healthy subjects at P = .005 and .05, respectively. The difference in hair calcium and magnesium levels in male patients with fibromyalgia and male healthy controls was not computed because there were only 3 paired samples.

As a group, patients with fibromyalgia had significantly higher hair calcium and magnesium levels than healthy controls. The difference for hair calcium and magnesium was highly significant at P = .025 and .05, respectively. This supports the hypothesis that hair calcium and magnesium levels in patients with fibromyalgia are higher than those in healthy subjects.

The conclusion, however, was subjected to some reservations. Although many measures have been used to assure validity of the findings, biases did occur. These included selection of subjects, number of subjects, diagnosis of the condition, and control of possible confounders. Subjects were sampled from only 1 clinic, and sampling bias could have occurred. Although selection of subjects was consecutive and was based on defined parameters, it could not be treated as random. Also, the number of patients used in the study was small. Diagnosis of fibromyalgia was essentially arrived at by exclusion and by its meeting certain defined criteria. Possibilities of diagnostic errors could not be ruled out entirely.

Forslind et al( 13) questioned if primary fibromyalgia exists. During a 5-year period in a tertiary care day ward for pain syndromes, they found that all of the 15 patients who had fulfilled criteria for fibromyalgia subsequently had psychiatric disturbance or thyroid dysfunction. Tender points determination, however, were less liable to error, despite being detected by digital pressure. Tender points were considered to be the best parameter for classifying fibromyalgia.( 22) The sensitivity of tender point count based on varying thresholds for positivity in suspected fibromyalgia was reported to be 90% to 95%, with specificity of 94% in healthy subjects and 78% in rheumatic control patients.( 8) The interrater reliability of identification of tender points was shown to be good and equally accurate when performed by dolorimetry and digital palpation.( 43) Also, the interrater reliability of classifying fibromyalgia based on tender point counts was good in controlled settings.( 43)

Another possible source of error was that the study was retrospective. A number of possible confounders were not taken into account. The types of shampoos, conditioners, medications, and nutritional supplements were not factored in.

Implications

The hair calcium and magnesium levels in patients with fibromyalgia are significantly higher than those of healthy subjects. The reason that high hair calcium and magnesium levels occur in patients with fibromyalgia is unknown. Although serious uncertainty exists about the meaningful interpretation of hair mineral data, including the relation between hair calcium and magnesium levels and their human body burdens, high hair calcium and magnesium levels have been conjectured to result from chronic dietary deficiency or bone demineralization, especially when many of the female patients with fibromyalgia are in perimenopausal years.

Yasui et al( 44) fed 4 groups of male Wistar rats diets that were normal in calcium, low in calcium, low in magnesium, low in calcium-magnesium, or low in calcium-magnesium with added aluminum for 4 week periods. They found marked increase in calcium concentrations in central nervous system and other soft tissues of rats maintained on low calcium diets, decreased concentrations of magnesium in spinal cord, and in bones of rats fed a low calcium-magnesium diet with added aluminium. They theorized that chronic unbalanced mineral diets may accelerate the mobilization of calcium and magnesium from bone and deposition of calcium in the brain.( 44) It is possible that some of the calcium and magnesium that are mobilized in the process deposit in the hair and bring about a high hair and magnesium level.

Yoshinaga et al( 42) measured calcium and magnesium levels in hair, various internal organs, and ribs of 46 Japanese people who had died suddenly, mainly from accidents. The health status of the subjects was not described. The mean age and SD of the subjects was 42.5 and 20.5 years, respectively. Yoshinaga et al( 42) found no significant correlation between the levels of hair calcium and magnesium and the concentrations of the elements in internal organs, including ribs. The finding is not unexpected. Hair is a biological tissue and serves as an accumulator of trace elements. It is formed in a relatively short period of time. During the growth cycle, the hair is expelled at a rate of 0.2 to 0.5 mm/day from the skin. It is thereafter isolated from the metabolic events in the human body. The minerals incorporated during the growth period no longer remain in dynamic equilibrium with the rest of the body( 11) and are not used in metabolism.( 42)

Despite the lack of correlation between the hair levels of calcium and magnesium and the concentrations in body tissues, Takagi et al( 11) believed that the hair elemental profiles indicate the status of trace elements in an individual at a specified time period.

Calcium and magnesium may play a role in fibromyalgia. It is speculated that as a result of chronic dietary deficiency or demineralization of bone, calcium is released into the bloodstream to maintain blood calcium homeostasis. Some of the liberated calcium may be deposited and stored in the hair. During the process, the calcium concentration in muscles may increase. The increase in muscle intracellular calcium level may produce myofiber damage through calcium-activated proteolytic enzyme activity( 45) and cause persistent muscle contraction without electromyographic activity. This uses adenosine triphosphate/phosphorylcreatine, depletes energy stores,( 46) and may result in muscle weakness.

Lund-Olesen and Lund-Olesen( 6) put forward a similar hypothesis to explain the pathogenesis of chronic fatigue syndrome/fibromyalgia. They hypothesized that calcium channels of striated muscle cells in the conditions are injured and that an increased amount of calcium is permitted to enter the cells. This results in increased muscular tone. Treatment of a woman aged 58 years with chronic fatigue syndrome for 15 years with calcium antagonist brought about an improvement in symptoms 4 to 5 days after beginning therapy. The improvement was dramatic during the next 5 weeks of treatment, and the patient was able to sleep for up to 6 hours per night. Attempt to discontinue the treatment after 10 weeks resulted in recurrence after 3 to 4 days. Lund-Olesen and Lund-Olesen( 6) suggested that the calcium antagonist acts by lowering the peripheral resistance and increasing the blood circulation through striated muscles.

Magnesium has also been found to relate to fibromyalgia. This is not unexpected as magnesium is nature's physiologic Calcium blocker. Eisinger et al( 4) studied indicators of glycolysis in 25 patients with fibromyalgia and compared them with 10 patients with hypothyroidism, 15 patients with osteoarticular chronic pain, and 36 healthy controls. They found that magnesium level decreased in red blood cells but increased in leukocytes in patients with fibromyalgia compared with the control group. Abraham and Flechas( 7) proposed that magnesium deficiency in muscle cells is a factor in the development of fibromyalgia. They demonstrated that a daily supplement of 300 to 600 mg of magnesium malate resulted in improvements in the number and severity of tender points. Eisinger et al( 4) concurred with the finding and suggested treating the muscle weakness in fibromyalgia with magnesium supplements. Nevertheless, they did not specify the dosage required. Also, the long-term response of fibromyalgia to magnesium supplements has not been studied.

The effects of intramuscular administration of magnesium in chronic fatigue syndrome, which bears similar clinical features to fibromyalgia, were also studied. In a double-blind, placebo-controlled clinical trial,( 47) 32 patients with chronic fatigue syndrome were allocated randomly to treatment and placebo groups. The treatment group consisted of 15 patients, and the placebo group consisted of 17 patients. Fifty percent magnesium sulphate (1 g of magnesium sulphate in 2 mL of injectable water) was injected intramuscularly to the patients in the treatment group once every week for 6 consecutive weeks. In contrast, the placebo group received intramuscular injection of 2 mL of water with equal frequency and over the same amount of time. After completion of the study, 12 of the 15 patients in the treated group reported increased energy levels and had a better emotional state and less pain. Seven of them had significant improvement in energy score. In contrast, 3 of the 17 patients in the placebo group felt better, but only 1 of them had more energy. Although the outcome measures used were subjective, the double-blind, placebo-controlled study made the findings internally valid. The finding suggested that magnesium is useful in the treatment of chronic fatigue syndrome. Whether the finding has any bearing on the treatment of fibromyalgia is unknown.

It does seem that calcium and magnesium may play a part in fibromyalgia. Yet the role of calcium and magnesium in fibromyalgia remains unknown. Also, the relation between hair calcium and magnesium and their body loads need to be explored.

CONCLUSION

The results showed that hair calcium and magnesium levels in patients with fibromyalgia are significantly higher than healthy control subjects. These findings support the hypothesis that the hair calcium and magnesium levels in patients with fibromyalgia are higher than those of healthy control subjects.

Although the relation between hair calcium and magnesium levels and their bodily burdens has not been previously studied, it is speculated that high hair calcium and magnesium levels indicate reduced bodily stores. Thus in the presence of high hair calcium and magnesium levels, calcium and magnesium supplements may be indicated as an adjunctive treatment. Certainly, the causes of possible body depletion of the elements, such as reduced intake of calcium containing foods and the use of diuretics, need to be addressed too.

Because this study involved only a small number of samples from 1 clinic and the biases and errors could not be ruled out entirely, further study may be required to elucidate the relation among hair calcium and magnesium levels and fibromyalgia.

Future study should preferably be prospective, with random sampling of subjects from a number of clinics. The number of subjects used should also be increased to improve the power from the present 0.7 to 0.8, which will then improve the internal validity of the study. Subjects should be observed for 2 to 3 years to ensure that fibromyalgia is not caused by other conditions.

Examination of tender points should preferably be performed by a second clinician who is blind to the diagnosis. This avoids overestimation of tender points and thus over-diagnosis. In addition, this permits confirmation of diagnosis by another clinician to reduce errors in patients' selection. Also, dolorimetry should be used to standardize the pressure placed on the tender spots. Efforts should also be made to decrease possible confounding factors, such as smoking, drug or mineral intake, and the use of hair treatment products.

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National College of Chiropractic.

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