Fibromyalgia is characterized by chronic, widespread pain, abnormal processing of pain and increased sensitivity to external stimuli, along with fatigue, gastrointestinal symptoms and changes in memory, mood and sleep [1] [2] [3] . In 2010 the American College of Rheumatology established diagnostic criteria for the diagnosis of fibromyalgia based on a pain index and symptom severity scale [2] . Using this diagnostic criteria it has been estimated that between 0.1% - 3.3% of the populations in western countries and 2.0% of the population of the United States have fibromyalgia, with higher incidence rates in females compared to males [4] .

In the last few years natural supplements have been used to reduce symptoms in patients with fibromyalgia, chronic fatigue and other chronic illnesses [5] ; however, few if any of these natural supplements were considered effective [6] . Some symptoms, such as fatigue and pain, also occur naturally during aging, and they are important secondary conditions in many chronic diseases [7] .

Pain and fatigue are related functionally to cellular energy systems found primarily in mitochondria and specifically in the electron transport chain of the mitochondrial inner membrane [8] [9] . Damage to mitochondrial membranes occurs in various diseases, mainly by oxidation of phospholipid components, and this can result in ion leakage across inner mitochondrial membranes and reductions in the ability of mitochondria to produce high-energy molecules [10] [11] . During aging and most chronic diseases the production of oxidative free radicals, such as Reactive Oxygen and Nitrogen species (ROS/RNS) and other molecules, can cause oxidative stress and cellular damage [10] [11] [12] . ROS/RNS damage often occurs to cellular membranes, and in particular, to the glycerolphospholipids of mitochondrial membranes [11] [12] [13] [14] .

Membrane Lipid Replacement (MLR) therapy plus antioxidants has been used to replace damaged glycerolphospholipids in various clinical disorders and in aged individuals [8] [14] [15] . MLR results in the replacement of damaged cellular lipids with undamaged, unoxidized lipids to ensure proper function of cellular and organelle membranes. Combined with antioxidants, MLR supplements have proven to be effective in reducing ROS/RNS-associated changes in cellular activities and functions and for reducing symptom severity and providing host support in various clinical conditions [8] [14] [15] [16] . In fibromyalgia patients, the MLR supplement NTFactor Lipids^Ò has been used to reduce fatigue [8] [16] . In a preliminary case report pain, fatigue and gastrointestinal symptoms were reduced in a small number of fibromyalgia patients (P.A. Breeding and G.L. Nicolson, in preparation)

In fibromyalgia patients another natural approach to reducing the severity of symptoms has been to use low-dose caffeine (equivalent to one or less than one cup of coffee or about 40 - 50 mg of caffeine) to moderate doses (equivalent to 1.5 - 2.5 cups of coffee) of caffeine to reduce pain and fatigue [17] . In the study of Scott et al. [17] caffeine consumption had a modest but significant effect on chronic pain reduction compared to an absence of caffeine consumption, but among non-opioid users this effect was not significant [17] . Caffeine is one of the most widely consumed natural food supplements in the world, and it is present in numerous foods and beverages. Caffeine is generally considered safe at doses up to 400 mg per day for adults [18] [19] .

Here we tested the results of a combination natural supplement that contained a formulation of MLR glycophospholipids (NTFactor Lipids^Ò) plus a low dose of controlled-released caffeine in chewable wafers in an open-label study format that used self-reported results on pain, fatigue, gastrointestinal symptoms and quality of life (QOL) indicators in a small group of fibromyalgia patinets.

Oral supplements that contain membrane glycerolphospholipids have been used successfully in several clinical MLR studies [8] [14] [15] [16] [26] [27] . Here we used the MLR supplement NTFactor Lipids^Ò with fructooligosaccahrides and antioxidants to protect the phospholipids from disruption, degradation and oxidation in the gut [14] [15] . These membrane glycerolphospholipids can be absorbed and transported into tissues and cells without excessive oxidative damage [8] [14] [15] . Once inside cells, the undamaged, replacement membrane phospholipids can exchange with damaged membrane phospholipids, resulting in removal of the latter molecules from cells. They also provide important lipid precursors for specific molecules, such as cardiolipin in the inner mitochondrial membrane. An important addition to the supplements we used was the incorporation of fructooligosaccharides and antioxidants in the MLR glycerolphospholipid mixture to avert oxidation and other types of damage to the phospholipids. This is important for maintaining potency during storage before they can be ingested and while they are ingested and dispersed into small lipid globules that are absorbed by the gut epithelium and transferred to the lymph and blood circulations for transport to various tissues and cells [8] [14] [15] .

In animal studies a similar MLR supplement was used to prevent age-associated hearing loss [28] . Hearing loss is normally associated with aging, but addition of MLR glycerolphospholipids to animal chow shifted the threshold hearing from 35 - 40 dB in control aged laboratory rats to 13 - 17 dB in the treatment group (p < 0.005). Seidman et al. also found that cochlear mitochondrial function was preserved, and aging-related mitochondrial DNA deletions found in the cochlear were significantly reduced in the animals receiving the glycerolphospholipid supplement in their chow [28] .

Most clinical studies using oral MLR supplements have been designed to reduce fatigue and protect cellular and mitochondrial membranes from oxidative damage [8] [14] [15] [16] . In some studies NTFactor^Ò has been used in a vitamin and mineral mixture (Propax^TM) for cancer patients to reduce the adverse effects of cancer therapy, such as chemotherapy-induced fatigue, nausea, vomiting and other side effects [29] [30] . In a double-blind, placebo-controlled, randomized cross-over trial on cancer patients receiving chemotherapy MLR improved fatigue scores, nausea, diarrhea, impaired taste, constipation, insomnia and improved QOL indicators [29] .

In several clinical studies MLR glycerolphospholipids have been shown to significantly reduce fatigue [8] [14] [15] [16] [27] [31] [32] [33] . For example, using aged subjects with chronic fatigue in a cross-over format, fatigue scores were significantly reduced from severe to moderate after eight weeks of MLR supplementation with NTFactor^Ò. Mitochondrial function also improved with administration of the MLR glycerolphospholipids [32] . After 12 weeks there was a 35.5% reduction in fatigue (p < 0.001), and there was good correspondence between reductions in fatigue and gains in mitochondrial function (p < 0.001). By 12 weeks of supplementation mitochondrial function was found to be similar to that of young, healthy adults [32] . However, when subjects were placed on placebo without their knowledge for an additional 12 weeks, their fatigue and mitochondrial function were intermediate between the initial starting values and those found after eight or 12 weeks on the MLR supplement [32] . Here fibromyalgia patients showed significant reductions in fatigue similar to those found in previous studies with fibromyalgia patients [27] .

In addition to fatigue, in the present study we also examined subjects for reductions in widespread pain and gastrointestinal symptoms, common complaints of fibromyalgia patients, as well as changes in QOL indicators. We found significant reductions in pain (p < 0.001) and gastrointestinal symptoms (p < 0.001) as well as improvements in QOL indicators (p < 0.001). The changes in fatigue, pain, gastrointestinal symptoms and QOL indicators were found to be significant on each day of the study (p < 0.001). Although there were differences between the responses of males and females in the study, consistent with previously studies, these differences were generally not statistically significant.

Using a mixed-effects statistical model and calculating Marginal and Conditional R² values indicated that the data were consistent and occurred with a low degree of variance. Although the number of subjects and time of the study were quite limited, the statistical analysis suggested that increasing the number of participants or the time of the study would be unlikely to change the conclusions. In fact, the results suggested that further reductions in overall scores, pain, fatigue, gastrointestinal symptoms and improvements in QOL were likely to occur with further time on the combination supplement.

Recently a case study with fibromyalgia patients using the MLR glycerolphospholipids (Patented Energy^TM wafers) without added controlled-release caffeine demonstrated that individual fibromyalgia patients evaluated in a clinic setting by specialists also showed reductions in pain, fatigue and gastrointestinal symptoms in the same time-frame as the current study (Breeding, P.A. and Nicolson, G.L. in preparation). This indicated that the effects seen here were not due to caffeine alone.

The formulation used in this clinical study contained controlled-release caffeine that delivered a modest dose of caffeine over eight hours. Caffeine in low to moderate doses has been used previously to reduce pain and other symptoms in patients with various diagnoses. Thirty clinical studies involving more than 10,000 patients have been conducted with combinations of drugs and caffeine to assess the value of caffeine as an added adjuvant [34] . For example, the pooled data on use of caffeine to increase the effectiveness of various analgesics compared to the analgesics alone have shown that caffeine can increase the overall relative potency by an estimated factor of 1.41 [34] . Vaeroy et al. [35] found that fibromyalgia patients benefited when a low dose of caffeine was added to a combination mixture of carisoprodol and paracetamol (acetaminophen) to reduce pain and other symptoms. When caffeine was in the mixture, the combination was more effective (p = 0.015) [35] . Here we did not compare caffeine alone to NTFactor Lipids alone or to the combination of NTFactor Lipids plus controlled-release caffeine, because the caffeine supplement that was under test (Brite Alert^TM) already contains NTFactor Lipids.

Although the etiology of fibromyalgia remains unclear, some of the possible causes are related to altered pain processing, resulting in malfunction at multiple levels. Some examples include aberrant ion channels, changes in intracellular Ca²⁺ and mitochondrial defects in neuroendocrine and skeletal muscle cell signal processing [36] [37] [38] [39] . Glycerolphospholipids and caffeine might act at these levels, and caffeine is known to be an important modulator of Ca²⁺ release in muscles and neuroendocrine cells [40] [41] . A recent study from our group supports the notion that NTFactor Lipids may act not just by replacement of damaged membrane glycerolphospholipids, but also by modulating and restoring the function of ion channels, intracellular Ca²⁺ and mitochondrial function [42] . The clinical trial results here are consistent with what has been described for the fibromyalgia syndrome etiology and the mechanism of action of NTFactor Lipids^Ò and caffeine.

We tested the hypothesis that NTFactor Lipids^Ò plus controlled-release, low-dose caffeine could reduce pain, fatigue, and gastrointestinal symptoms while improving QOL scores in fibromyalgia patients. Within days we found significant self-reported improvements in patients taking the combined supplement. The supplement was safe and effective and significantly reduced pain, fatigue and gastrointestinal symptoms and enhanced QOL scores during the 8-day period of the study. Although the number of patients in the study was limited, the statistical analysis suggested that increased numbers of participants would be unlikely to change the conclusions.

The authors would like to thank Allergy Research Group, Inc., Nutritional Therapeutics, Inc. and the Institute for Molecular Medicine for clinical trial financial support and for providing study materials.

Garth L. Nicolson and Robert Settineri are part-time consultants to Allergy Research Group, Inc. and Nutritional Therapeutics, Inc. Gonzalo Ferreira and Paul Breeding have no conflicts to disclose.

The authors declare no conflicts of interest regarding the publication of this paper.

Nicolson, G.L., Settineri, R., Ferreira, G. and Breeding, P. (2018) Reduction of Pain, Fatigue, Gastrointestinal and Other Symptoms and Improvement in Quality of Life Indicators in Fibromyalgia Patients with Membrane Lipid Replacement Glycerolphospholipids and Controlled-Release Caffeine. International Journal of Clinical Medicine, 9, 600-619. https://doi.org/10.4236/ijcm.2018.97051

Supplementary Figure 1. The signs/symptoms survey form used for this study. Participants were directed to fill out the form in the evening on the indicated days of the study and return the form to the Institute for Molecular Medicine.

Supplementary Table 1. Mean scores and SEM by day for each variable (each question in the symptom survey form).