Fibromyalgia Syndrome (fibromyalgia) is a condition which is characterized by a syndrome of generalized musculoskeletal pain, aches, stiffness, and tenderness at specific anatomical sites. Since it was first described, fibromyalgia has become recognized as a fairly common rheumatic complaint with a clinical prevalence of 6 to 20%. Additionally, fibromyalgia has been associated with irritable bowel syndrome, tension headache, mitral valve prolapse, and Chronic Fatigue Syndrome, to name a few.
In recent years, evidence has accumulated to suggest that the pain associated with fibromyalgia may be the result of local hypoxia to the muscles. Patients with fibromyalgia have low muscle-tissue oxygen pressure in affected muscles, and to a lesser degree the same is true of other tissues. Muscle biopsies from affected areas showed muscle tissue glycolysis is inhibited, reducing ATP synthesis. This stimulates the process of gluconeogenesis, which results in muscle tissue breakdown and mitochondrial damage. Additionally, low levels of the high-energy phosphates ATP, ADP, and phosphocreatine were found. It is hypothesized that in hypoxic muscle tissue, glycolysis is inhibited, reducing ATP synthesis. This muscle tissue breakdown, which has been observed in muscle biopsies taken from fibromyalgia patients, is hypothesized to result in the muscle pain characteristic of fibromyalgia.
Malic acid is synthesized in the body through the citric acid cycle. Its importance to the production of energy in the body during both aerobic and anaerobic conditions is well established. Under aerobic conditions, the oxidation of malate to oxaloacetate provides reducing equivalents to the mitochondria through the malate-aspartate redox shuttle. During anaerobic conditions, where a buildup of excess of reducing equivalents inhibits glycolysis, malic acid’s simultaneous reduction to succinate and oxidation to oxaloacetate is capable of removing the accumulating reducing equivalents. This allows malic acid to reverse hypoxia’s inhibition of glycolysis and energy production, possibly improving energy production in fibromyalgia, and reversing the negative effect of the relative hypoxia that has been found in these patients.
Because of its obvious relationship to energy depletion during exercise, malic acid may be of benefit to healthy individuals interested in maximizing their energy production, as well as those with Fibromyalgia, or Chronic Fatigue Syndrome.
As a result of the compelling evidence that malic acid plays a central role in energy production, especially during hypoxic conditions, malic acid supplements have been examined for their effects on fibromyalgia. Subjective improvement in pain was observed within 48 hours of supplementation with 1200-2400 mg of malic acid, (with higher doses being more effective), and this improvement was lost following the discontinuation of malic acid for 48 hours. While these studies also used magnesium supplements, due to the fact that magnesium is often low in fibromyalgia patients, the rapid improvement following malic acid, as well as the rapid deterioration after discontinuation, suggests that malic acid is the most important component. This interesting theory of localized hypoxia in fibromyalgia, and the ability of malic acid to overcome the block in energy production that this causes, should provide hope for those afflicted with fibromyalgia.
Additionally, many hypoxia-related conditions such as respiratory and circulatory insufficiency, are associated with deficient energy production. Therefore, malic acid supplements may be of benefit in these conditions. Chronic Fatigue Syndrome has also been found to be associated with fibromyalgia, and malic acid supplementation may be of use in improving energy production in this condition as well. Lastly, malic acid may be of use as a general supplement, ensuring an optimal level of malic acid within the cells, and thus, maintaining an optimal level of energy production.
It is very important that the L-isomer of Malic acid is used as it is the active form that exists naturally. When synthesised the malic acid produced contains both the D- and L- forms with the D- form being inactive. When extracted from apples only the L-form (active form) is present.
For more information and alternate treatments for fibromyalgia see the chronic fatigue/fibromyalgia article in our adrenal health section.