The art of MFR

The art of MFR

our physicians are accecepting its existance now...!!!!

The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee
Arthritis Rheum. 1990 Feb;33(2):160-72.

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al.



To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.


Fibromyalgia syndrome: Canadian clinical working case definition, diagnostic and treatment protocols- A consensus document
J Musculoskeletal Pain, 2004; 11(4): 3-107
Jain AK, Carruthers BM, van de Sande MI, Barron SR, Donaldson CCS, Dunne JV, Gingrich E, Heffez DS, Leung FYK, Malone DG, Romano TJ, Russell IJ, Saul D, Seibel DG.



Background: There has been a growing recognition of the need for information about objective abnormalities in people with the fibromyalgia syndrome [FMS] and for an integrated approach to its diagnosis and management by primary care physicians.



Objectives: To establish an expert consensus toward a working case definition of FMS and a working guide to its management for physicians in Canada.


Methods: An Expert Subcommittee of Health Canada established the Terms of Reference and selected an Expert Medical Consensus Panel representing treating physicians, teaching faculty, and researchers. The editors prepared a draft document which was reviewed by the Panel members in preparation for the Consensus Workshop, which was held on March 30 to April 1, 2001. Subsequent writing assignments produced subdocuments on key topics relevant to the objectives. The subdocuments were then integrated into a submission document which was approved by each of the panel members.


Results: The completed document is provided. It contains sections on a new approach to case definition, on proposed research to validate the new case definition, on a practical approach to assessment of severity, on empathetic management; and on what is known about pathogenesis.


Conclusions: A consensus document was developed to assist clinicians in distinguishing FMS from other syndromes/illnesses that may present with body pain. It is intended that this document serve as a guide: to a better understanding of FMS; to a more reasoned approach to its management; and to further research on the clinical care of people with FMS.


Fibromyalgia: more than just a musculoskeletal disease
Am Fam Physician. 1995 Sep 1;52(3):843-51, 853-4.
Clauw DJ.


Fibromyalgia is a common condition characterized by diffuse musculoskeletal pain and fatigue. The syndrome is defined by the presence of musculoskeletal tender points on physical examination. Additionally, persons with this syndrome have a high incidence of headaches, ocular and vestibular complaints, paresthesias, esophageal dysmotility, "allergic" symptoms, irritable bowl syndrome, genitourinary symptoms and affective disorders. Recent research has revealed a number of objective biochemical, hormonal and neurotransmitter abnormalities associated with fibromyalgia, making it a clearly identifiable condition. These abnormalities may clarify our understanding of the pathogenesis and treatment of fibromyalgia.


Fibromyalgia syndrome
J. Rheumatol. 2005 Nov;32(11):2270-7.
Mease PJ, Clauw DJ, Arnold LM, Goldenberg DL, Witter J, Williams DA, Simon LS, Strand CV, Bramson C, Martin S, Wright TM, Littman B, Wernicke JF, Gendreau RM, Crofford LJ.


The objectives of the first OMERACT Fibromyalgia Syndrome (FM) Workshop were to identify and prioritize symptom domains that should be consistently evaluated in FM clinical trials, and to identify aspects of domains and outcome measures that should be part of a concerted research agenda of FM researchers. Such an effort will help standardize and improve the quality of outcomes research in FM. A principal assumption in this workshop has been that there exists a clinical syndrome, generally known as FM, characterized by chronic widespread pain typically associated with fatigue, sleep disturbance, mood disturbance, and other symptoms and signs, and considered to be related to central neuromodulatory dysregulation. FM can be diagnosed using 1990 American College of Rheumatology criteria. In preparation for the workshop a Delphi exercise involving 23 FM researchers was conducted to establish a preliminary prioritization of domains of inquiry. At the OMERACT meeting, the workshop included presentation of the Delphi results; a review of placebo-controlled trials of FM treatment, with a focus on the outcome measures used and their performance; a panel discussion of the key issues in FM trials, from both an investigator and regulatory agency perspective; and a voting process by the workshop attendees. The results of the workshop were presented in the plenary session on the final day of the meeting. A prioritized list of domains of FM to be investigated was thus developed, key issues and controversies in the field were debated, and consensus on a research agenda on outcome measure development was reached.


Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study
Rheumatol Int. 2008 Sep 27.

de Souza JB, Goffaux P, Julien N, Potvin S, Charest J, Marchand S.


The main goal of this project was to identify the presence of fibromyalgia (FM) subgroups using a simple and frequently used clinical tool, the Fibromyalgia Impact Questionnaire (FIQ). A total of 61 women diagnosed with FM participated in this study. FM subgroups were created by applying a hierarchical cluster analysis on selected items of the FIQ (pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms). We also tested for group differences on experimental pain, psychosocial functioning and demographic characteristics. Two cluster profiles best fit our data. FM-Type I was characterized by the lowest levels of anxiety, depressive and morning tiredness symptoms, while FM-Type II was characterized by elevated levels of pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms. Both FM subgroups showed hyperalgesic responses to experimental pain. These results suggest that pain and stiffness are universal symptoms of the disorder but that psychological distress is a feature present only in some patients.


Chronic widespread pain and fibromyalgia: what we know, and what we need to know
Best Pract Res Clin Rheumatol. 2003 Aug;17(4):685-701.
Clauw DJ, Crofford LJ.


Fibromyalgia (FM) is currently defined as the presence of both chronic widespread pain (CWP) and the finding of 11/18 tender points on examination. Only about 20% of individuals in the population with CWP also have 11/18 tender points; these individuals are considerably more likely to be female, and have higher levels of psychological distress. There is no clear clinical diagnosis for the other 80% of individuals with less than 11/18 tender points, but it is likely that these persons, like FM patients, also have pain that is 'central' (i.e. not due to inflammation or damage of structures) rather than peripheral in nature. Research into FM has taught us a great deal about the confluence of neurobiological, psychological and behavioural factors that can cause chronic central pain. These conditions respond best to a combination of symptom-based pharmacological therapies, and non-pharmacological therapies such as exercise and cognitive behavioural therapy. In contrast to drugs that work for peripheral pain due to damage or inflammation (e.g. NSAIDs, corticosteroids), neuroactive compounds [especially those that raise central levels of noradrenaline (norepinephrine) or serotonin] are most effective for treating central pain.


Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment
J Rheumatol Suppl. 2005 Aug;75:6-21.
Mease P.


Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population in the USA and other regions in the world where FM is studied. Prevalence rates in some regions have not been ascertained and may be influenced by differences in cultural norms regarding the definition and attribution of chronic pain states. Chronic, widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FM is not completely understood, the syndrome is thought to arise from influencing factors such as stress, medical illness, and a variety of pain conditions in some, but not all patients, in conjunction with a variety of neurotransmitter and neuroendocrine disturbances. These include reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. A unifying hypothesis is that FM results from sensitization of the central nervous system. Establishing diagnosis and evaluating effects of therapy in patients with FM may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. Diagnostic criteria, originally developed for research purposes, have aided our understanding of this patient population in both research and clinical settings, but need further refinement as our knowledge about chronic widespread pain evolves. Outcome measures, borrowed from clinical research in pain, rheumatology, neurology, and psychiatry, are able to distinguish treatment response in specific symptom domains. Further work is necessary to validate these measures in FM. In addition, work is under way to develop composite response criteria, intended to address the multidimensional nature of this syndrome. A range of medical treatments, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been used to treat FM. Nonpharmaceutical treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can be helpful. Few of these approaches have been demonstrated to have clear-cut benefits in randomized controlled trials. However, there is now increased interest as more effective treatments are developed and our ability to accurately measure effect of treatment has improved. The multifaceted nature of FM suggests that multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with this syndrome.

We can cure your Fibromyalgia

About Fibromyalgia

Fibromyalgia (pronounced fy-bro-my-AL-ja) is a common and complex chronic pain disorder that affects people physically, mentally and socially. Fibromyalgia is a syndrome rather than a disease. Unlike a disease, which is a medical condition with a specific cause or causes and recognizable signs and symptoms, a syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

Fibromyalgia, which has also been referred to as fibromyalgia syndrome, fibromyositis and fibrositis, is characterized by chronic widespread pain, multiple tender points, abnormal pain processing, sleep disturbances, fatigue and often psychological distress. For those with severe symptoms, fibromyalgia can be extremely debilitating and interfere with basic daily activities.

Whether you have been diagnosed with fibromyalgia or suffer from its symptoms, or have a family member or friend with the disorder, this section is designed to provide you with a better understanding of this chronic pain disorder that affects millions of people worldwide.

Prevalence

Fibromyalgia is one of the most common chronic pain conditions. The disorder affects an estimated 10 million people in the U.S. and an estimated 3-6% of the world population. While it is most prevalent in women —75-90 percent of the people who have FM are women —it also occurs in men and children of all ethnic groups. The disorder is often seen in families, among siblings or mothers and their children. The diagnosis is usually made between the ages of 20 to 50 years, but the incidence rises with age so that by age 80, approximately 8% of adults meet the American College of Rheumatology classification of fibromyalgia.

Symptoms

Chronic widespread body pain is the primary symptom of fibromyalgia. Most people with fibromyalgia also experience moderate to extreme fatigue, sleep disturbances, sensitivity to touch, light, and sound, and cognitive difficulties. Many individuals also experience a number of other symptoms and overlapping conditions, such as irritable bowel syndrome, lupus and arthritis.
• Pain
The pain of fibromyalgia is profound, chronic and widespread. It can migrate to all parts of the body and vary in intensity. FM pain has been described as stabbing and shooting pain and deep muscular aching, throbbing, and twitching. Neurological complaints such as numbness, tingling, and burning are often present and add to the discomfort of the patient. The severity of the pain and stiffness is often worse in the morning. Aggravating factors that affect pain include cold/humid weather, non-restorative sleep, physical and mental fatigue, excessive physical activity, physical inactivity, anxiety and stress.
• Fatigue
In today's world many people complain of fatigue; however, the fatigue of FM is much more than being tired after a particularly busy day or after a sleepless night. The fatigue of FM is an all-encompassing exhaustion that can interfere with occupational, personal, social or educational activities. Symptoms include profound exhaustion and poor stamina
• Sleep problems
Many fibromyalgia patients have an associated sleep disorder that prevents them from getting deep, restful, restorative sleep. Medical researchers have documented specific and distinctive abnormalities in the Stage 4 deep sleep of FM patients. During sleep, individuals with FM are constantly interrupted by bursts of awake-like brain activity, limiting the amount of time they spend in deep sleep.
• Other symptoms/overlapping conditions
Additional symptoms may include: irritable bowel and bladder, headaches and migraines, restless legs syndrome (periodic limb movement disorder), impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, Raynaud's Syndrome, neurological symptoms, and impaired coordination.
Causes

While the underlying cause or causes of FM still remain a mystery, new research findings continue to bring us closer to understanding the basic mechanisms of fibromyalgia. Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain amplification due to abnormal sensory processing in the central nervous system. An increasing number of scientific studies now show multiple physiological abnormalities in the FM patient, including: increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function.

Recent studies show that genetic factors may predispose individuals to a genetic susceptibility to FM. For some, the onset of FM is slow; however, in a large percentage of patients the onset is triggered by an illness or injury that causes trauma to the body. These events may act to incite an undetected physiological problem already present.

Exciting new research has also begun in the areas of brain imaging and neurosurgery. Ongoing research will test the hypothesis that FM is caused by an interpretative defect in the central nervous system that brings about abnormal pain perception. Medical researchers have just begun to untangle the truths about this life-altering disease.

Prognosis

While there is currently no cure for fibromyalgia, better ways to diagnose and treat the chronic pain disorder continue to be developed. Since June 2007, the U.S. Food and Drug Administration has approved three medications for the treatment of fibromyalgia and other FM medications are currently in development. Research efforts have expanded as well. In 1990 there were approximately 200 published research papers on fibromyalgia studies. Today there are more than 4,000 published reports.

While many strides have been made in the last decade, fibromyalgia remains a challenging condition. However, clinical studies have demonstrated that fibromyalgia patients can reduce their symptoms through a variety of treatment options. Working in conjunction with knowledgeable healthcare professions, motivated and informed patients can experience significant improvement in their symptoms and quality of life. Developing an individualize self-management plan, from identifying effective treatments approaches to making necessary lifestyle changes, will further improve one’s health

Treatment

One of the most important factors in improving the symptoms of FM is for the patient to recognize the need for lifestyle adaptation. Most people are resistant to change because it implies adjustment, discomfort and effort. However, in the case of FM, change can bring about recognizable improvement in function and quality of life. Becoming educated about FM gives the patient more potential for improvement.

An empathetic physician who is knowledgeable about the diagnosis and treatment of FM and who will listen to and work with the patient is an important component of treatment. It may be a family practitioner, an internist, or a specialist (rheumatologist or neurologist, for example). Conventional medical intervention may be only part of a potential treatment program. Alternative treatments, nutrition, relaxation techniques, and exercise play an important role in FM treatment as well. Each patient should, with the input of a healthcare practitioner, establish a multifaceted and individualized approach that works for them.
• Pain management
A number of pharmacological treatments for fibromyalgia are available for prescription. The first to be approved by the U.S. Food and Drug Administration to treat fibromyalgia was pregabalin (Lyrica®); the second was duloxetine (Cymbalta®); and the third was milnacipran (Savella®). Other FM medications are currently in development, and may soon receive FDA approval to treat fibromyalgia. Additionally, healthcare providers may treat patients' FM symptoms with non-narcotic pain relievers (e.g. tramadol) or low doses of antidepressants (e.g. tricyclic antidepressants, serotonin reuptake inhibitors) or benzodiazepines. Patients must remember that antidepressants are "serotonin builders" and can be prescribed at low levels to help improve sleep and relieve pain. If the patient is experiencing depression, higher levels of these or other medications may need to be prescribed. Lidocaine injections into the patient's tender points also work well on localized areas of pain. An important aspect of pain management is a regular program of gentle exercise and stretching, which helps maintain muscle tone and reduces pain and stiffness.
• Sleep management
Improved sleep can be obtained by implementing a healthy sleep regimen. This includes going to bed and getting up at the same time every day; making sure that the sleeping environment is conducive to sleep (i.e. quiet, free from distractions, a comfortable room temperature, a supportive bed); avoiding caffeine, sugar, and alcohol before bed; doing some type of light exercise during the day; avoiding eating immediately before bedtime; and practicing relaxation exercises as you fall to sleep. When necessary, there are new sleep medications that can be prescribed, some of which can be especially helpful if the patient's sleep is disturbed by restless legs or periodic limb movement disorder.
• Psychological support
Learning to live with a chronic illness often challenges an individual emotionally. The FM patient needs to develop a program that provides emotional support and increases communication with family and friends. Many communities throughout the United States and abroad have organized fibromyalgia support groups. These groups often provide important information and have guest speakers who discuss subjects of particular interest to the FM patient. Counseling sessions with a trained professional may help improve communication and understanding about the illness and help to build healthier relationships within the patient's family.
• Other treatments
Complementary therapies can be very beneficial. These include: physical therapy, therapeutic massage, myofascial release therapy, water therapy, light aerobics, acupressure, application of heat or cold, acupuncture, yoga, relaxation exercises, breathing techniques, aromatherapy, cognitive therapy, biofeedback, herbs, nutritional supplements, and osteopathic or chiropractic manipulation.

Pain tracker

What’s the benefit to keeping track of your pain? You can monitor it over a period of time and start to identify patterns, which can ultimately help you manage your pain. For example, one kind of activity may exacerbate pain while another may soothe it.

Calendar

Tracking your pain is simple: Use a calendar like format. Just write your pain details on it on a day in the calendar or add more details to a previous one. Forgot when your last entry was? The indicates existing entries.
Create a Report
View and print your pain history to discuss with your doctor.

In 1990 the American College of Rheumatology developed the tender point exam, which maps 18 specific points on the body that are extremely sensitive in people with fibromyalgia. In order for your doctor to diagnose you with fibromyalgia, you need to experience pain in at least 11 of these points and have constant, widespread pain for at least three months.
When mild pressure is applied to any of these soft-tissue tender point areas around the neck, shoulder, chest, hip, knee and elbow regions, a patient with fibromyalgia often experiences it as pain. Another symptom: applying pressure to these points may trigger pain in a larger region, such as down your leg.
If you have widespread, frequent pain, above and below the waist, on both sides of your body, and in the neck, chest, or back, ask your doctor to administer the tender point test for a definitive fibromyalgia diagnosis. Once you’ve gotten a diagnosis you can begin to create a treatment plan to help you manage your symptoms
Our approach

• Myofascial Unwinding for balancing the body
• Diet and Exercise Can Calm Fibromyalgia Symptoms
• Alternatives Abound in Fibromyalgia Treatment
• Manage Stress, Manage Fibromyalgia
• Proper Sleep Is Crucial to Managing Fibromyalgia

Put Together Your Fibromyalgia Treatment Plan

If you have the flu, spend a few days in bed, and you’ll likely feel better. Fibromyalgia is different. Symptoms are eased, never cured, and there is no one “remedy” that works for everyone. For these reasons, fibromyalgia patients should develop a personalized treatment plan to minimize flare-ups and the severity of symptoms.
Identify your symptoms
Widespread, chronic pain is a hallmark of fibromyalgia. It’s diagnosed by the presence of tenderness in 18 specific points of the body, with at least 11 of those 18 spots being abnormally tender, even when mildly touched. Fatigue, sleep, and memory and concentration problems (often called “fibro fog”) also are common symptoms of fibromyalgia. You might also experience restless legs syndrome, irritable bowel syndrome, painful menstruation, depression, dry eyes, anxiety or headaches. Make sure you work with your doctor to treat all of your ailments.
Find the right medications
To date, pregabalin (Lyrica), duloxetine (Cymbalta) and milnacipran (Savella) are the only medications approved by the U.S. Food and Drug Administration (FDA) to treat fibromyalgia pain. Tricyclic antidepressants often have been found to be the most efficacious medications for fibromyalgia, especially since sleep and fatigue problems respond well to some antidepressants. But other painkillers, from over-the-counter ibuprofen to prescription-only narcotics, also are prescribed.
Talk to your doctor about what will give you the greatest relief with the fewest side effects. Because there are so many medications to choose from, you may need to use trial and error to help determine which is best for you. If antidepressants don’t work, you may need to incorporate sleep aids or muscle relaxants into your treatment plan.
Explore alternative treatments
For many people, massage and acupuncture, as well as Pilates, tai chi, chiropractic treatment, and various dietary supplements, can provide relief. You also may find it helpful to work with a physician who incorporates complementary medicine into his or her practice.
Make healthy changes
Stress reduction, a healthy diet and regular exercise can reduce fibromyalgia flare-ups, so lifestyle changes should be a part of your treatment plan. Sleep also is crucial for managing symptoms. Devising a treatment plan will require coordinating with your primary care doctor and/or a rheumatologist, physical therapist, naturopathic physician (if you use one) and other health professionals. Make sure everyone on your health care team is aware of your plan, and consult your doctor before making adjustments.

Myofascial Unwinding for balancing the body
Myofascial Unwinding is an advanced form of Myofascial Release technique, which is intended to reduce the increased body pressure or tension aroused due to myofascial dysfunction; which is the cause of the debilitating pain suffered by fibromyalgic patients.
Here a myofascial practitioner applies well controlled forces and stretches to the body by using extremities as lever. It’s a slow procedure and need 2-3 months of treatment for its complete cure. In my experience MFU is the only effective technique in its management. If MFU can be combined with the below described procedures; the effects will be four fold.
Diet and Exercise Can Calm Fibromyalgia Symptoms

A healthy diet and regular exercise are essential to anyone who wants to feel well. For someone with fibromyalgia, those two things play a critical role in helping to reduce pain, increase energy and improve quality of life.
Studies have shown that walking, strength training, stretching exercises and swimming in a heated pool can alleviate fibromyalgia symptoms. Regular exercise appears to enhance the body’s response to stress, which often triggers symptoms. It also improves endocrine function to help the body better process pain and regulate sleep patterns.
Here are the keys to an effective exercise program:
• Start slowly. Begin with gentle stretching, walking, bicycling or swimming.
Create a routine. Exercise should be a regular part of your life. Schedule time for it on your weekly calendar and take advantage of small opportunities to exercise throughout your day, such as using the stairs instead of the elevator.

• Have fun with it. Yoga, Pilates, strength training, tai chi, bicycling, walking, jogging, low-impact aerobics or swimming all are recommended. Mix it up so you won’t get bored.
While exercise is one of the most proven ways to battle fibromyalgia, the jury is still out on the issue of nutrition. A balanced diet can help increase your energy level and reduce your risk of other health problems, but more research is needed before experts can identify if specific foods affect the risk of flare-ups. Many people with fibromyalgia, however, have reported a reduction in symptoms by avoiding certain things, such as caffeine and alcohol. Experiment by cutting foods from your diet that seem to intensify your symptoms. To maintain your health, though, make sure your diet remains well-balanced.
Improving your diet can make you healthier and may even reduce your pain and fatigue. Add that to a regular exercise regimen and you may be on the road to more pain-free days.

Proper Sleep Is Crucial to Managing Fibromyalgia

It’s a vicious cycle: A poor night’s sleep makes your fibromyalgia symptoms worse, and then the pain makes it hard to fall asleep at night. Restless legs syndrome, a problem for many people with fibromyalgia, also can keep you from getting the rest you need.
Sleep is a crucial piece of the fibromyalgia puzzle. In fact, some research shows that disruptions during the deepest levels of sleep can cause the onset of fibromyalgia symptoms.
Try these suggestions to get better sleep:
Adopt a daily routine
Try to go to bed and wake up at the same time each day. Avoid daytime napping and create a nighttime relaxation ritual. This could include a warm bath, reading or listening to music as a way to wind down.
Watch your diet
Avoid caffeine and alcohol in the late afternoon and evening. Caffeine can make it harder to fall asleep and alcohol can disrupt sleep. Also, avoid spicy or fried foods if they cause heartburn or indigestion. And so your bladder won’t wake you, try not to consume any liquids right before bed.
Time your workouts
Exercise can help you sleep better at night. Some experts advise finishing at least three hours before bedtime because the stimulation may make it difficult to fall asleep right away. Others, however, point out that exercise can relax you and help you fall asleep shortly after participating in it.
Medication can help
If lifestyle changes are not enough, medication is an option. Tricyclic antidepressants can help you achieve restorative sleep, but they may leave you drowsy during the day. If you have restless legs syndrome, your doctor may prescribe sedatives such as diazepam (Valium). On the downside, the extended use of benzodiazepines can lower your pain threshold and ultimately exacerbate pain. Plus, they can be extremely addictive. Sleep medications and muscle relaxants can also help, so talk to your doctor about your options.

Manage Stress, Manage Fibromyalgia

When you have fibromyalgia, stress has a powerful grip on your life. It can cause the disease to flare-up, resulting in shooting pains, extreme fatigue, and cognitive problems like confusion and memory loss—often called “fibro fog.” In fact, many people report that a traumatic event brought on their first symptoms of fibromyalgia, leading some researchers to speculate that stress can actually trigger the disease. The National Institute of Arthritis and Musculoskeletal and Skin Diseases currently is funding research into whether fibromyalgia is caused by a breakdown in the way the body responds to stress.
Stress is known to trigger flare-ups in people with fibromyalgia, so restoring calm to your everyday life can help reduce your symptoms. Here are some coping techniques that can help you have more pain-free days.
Identify Your Stressors
Analyze your day and look for potential stress hot spots. For example, some people don’t mind sitting in traffic, but others fume as they creep along during rush hour. If you feel hurried to get out the door on time every morning, consider waking up earlier (and going to bed earlier to compensate). If talking on the phone to a certain family member is stressful, consider changing to an email-only relationship. Figure out which situations you can control and make the necessary adjustments to make your days easier.
Develop Coping Techniques
Much of life’s stress is unavoidable, but you can learn to react to it while keeping your calm:
• Schedule time to relax or meditate every day. The more you do it, the better you’ll get at relaxing. Then, when you experience a sudden stressful situation, such as a heated discussion with your boss, you’ll know how to take a few minutes afterward for deep breathing exercises or a short walk.
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• Don’t dwell on the past. One component of stress involves regret over things we could have done differently. Live in the moment and focus on what you need to do now to control your illness.
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• Request accommodations at work. If your fibromyalgia makes mornings difficult, ask to work from 10 a.m. to 6 p.m., for example, instead of from 9 a.m. to 5 p.m. If sitting at your desk all day leaves your body aching, ask for a better chair or for regular breaks so you can walk and stretch.
•
• Find support. Talk to others who have fibromyalgia to share coping strategies and encouragement during your bad days.
Managing stress will not cure your fibromyalgia, but it can help you gain some control over your symptoms. Allow yourself to relax and your body will thank you
Alternatives Abound in Fibromyalgia Treatment

Odds are if you have fibromyalgia, you have heard about alternative treatments that may help you feel better. In fact, 90 percent of fibromyalgia patients have reported trying such alternative therapies as massage, acupuncture, dietary supplements or chiropractic treatment to ease their symptoms.
While research has yet to prove that all alternative therapies work in treating fibromyalgia, there is a lot of evidence that supports acupuncture as a successful treatment. Using super-thin needles, acupuncturists stimulate various pressure points to provide pain relief. Some studies show that electroacupuncture, in which an electric current is pulsed through a needle, is more effective than the traditional method.
Many people with fibromyalgia find different alternative methods effective. And like mainstream fibromyalgia treatments, what works for one person might have no effect on another. Bottom line: You have to shop around to see what is best for you.
Here are some other options:
Massage: Massage therapists work on the muscles and soft tissue of the body to alleviate pain, muscle spasms and stress. However, the National Center for Complementary and Alternative Medicine reviewed research about the effectiveness of treating fibromyalgia with massage and found that the benefits are only short-term.
Cognitive behavioral therapy: Often called CBT, cognitive behavioral therapy has been shown to be among the most effective non-medication treatments for fibromyalgia. CBT helps change the way you think about pain with the goal of changing the way your body responds to pain, thus making the pain less severe. It may also help improve sleep.
Though studies on the following methods have been deemed insufficient by some medical experts, they are still widely used by people with fibromyalgia, with varying degrees of success.
Dietary supplements magnesium and SAM-e are often used to treat fibromyalgia. SAM-e is a naturally occurring compound in our bodies that helps in the production of dopamine and serotonin, which regulate mood and control the pain response. Preliminary research has shown evidence that SAM-e supplements may work to keep symptoms in check, but further study is needed. Magnesium is helpful in hundreds of ways, like converting food into energy, strengthening the immune system, and maintaining normal nerve and muscle function. Some researchers believe that a deficiency of this mineral contributes to fibromyalgia symptoms, though research into its efficacy has been inconclusive.
Finding the alternative treatment that works for you will require some experimentation. Ask your doctor for recommendations and be sure to tell him or her which treatments you already are using. This is especially important with dietary and herbal supplements since they can interact with other medications and possibly cause side effects.

For more details please contact Dr. Ajimshaw @ dr.ajimshaw@rediffmail.com or ajimsha@aimst.edu.my

Fibromyalgia and its Sufferings

Understanding Chronic Pain and Fibromyalgia: A Review of Recent Discoveries


Fibromyalgia tends to be treated rather dismissively, sometimes with cynical overtones. When I trained in BPT some 10 years ago, this diagnosis was never mentioned. In the United States fibromyalgia has become a semi-respectable diagnosis within the last 10 years, but even so it has some critics. The problem for doctors is that fibromyalgia is not a problem that can be understood according to the classic medical model. This is the model that is used in all medical training. It is based on the correlation of specific tissue pathology with distinctive symptoms (e.g. tuberculosis of the lung causing a chronic cough). Elimination of the causative agent (e.g. the tubercule bacillus) cures the disease. This model has led to the most major advances in medicine that we benefit from today.

I have seen over 150 fibromyalgia patients over the past 5 years; most want to be reassured that their symptoms are the product of a "real disease" rather than figments of a fertile imagination--commonly ascribed to the psychological diagnosis such as somatization, hypochondriasis, or depression. The good news is that contemporary research is hot on the track of unraveling the changes that occur within the nervous system of fibromyalgia patients. The basic message is that fibromyalgia cannot be considered a primarily psychological disorder, but as in many chronic conditions, psychological factors may play a role in who becomes disabled and may even up-regulate the central nervous system changes that are the root cause of the problem.

What is the problem?
The problem is: disordered sensory processing.
I will try to convey to you what we mean by "disordered sensory processing." Even a superficial understanding of this topic will change the way you think about the fibromyalgia problem. Furthermore, recent advances that have been made at the molecular level hold out the promise of more effective treatment for fibromyalgia pain.

What is Fibromyalgia?
Fibromyalgia is a chronic pain state in which the nerve stimuli causing pain originates mainly in the muscle. Hence the increased pain on movement and the aggravation of fibromyalgia by strenuous exertion.

Pain is a universal experience that serves the vital function of triggering avoidance. A few unfortunate individuals have a congenital absence of pain sensation; they do not fare well due to repeated bodily insults that go unnoticed. As a physician I see patients with an acquired deficiency in the pain sensation (e.g. diabetic neuropathy or neurosyphilis) who develop a severe destructive arthritis--a result of repeated minor joint injuries that are overlooked. Thus pain sensation is a necessary part of being human. Pain sensation is a fact of life. Even the primitive amoeba takes avoiding action in the face of adverse events. In such primitive life forms, pain avoidance is purely reflex action, as they do not have the complexity of a highly developed brain to feel pain in the sense that humans do: (1)The unconscious reflex avoidance reaction that is so rapid that it occurs before the actual awareness of the pain sensation (as in all life forms), (2) the actual experience of the pain sensation (that can only occur in highly complex organisms). This is an important point, as it implies that different parts of the brain are involved in these two consequences of the pain reaction.

Over the last few years a number of important research discoveries have started to clarify the enigma of chronic pain. Many of these new findings have a special relevance to the chronic pain of fibromyalgia. The cardinal symptom of FM is widespread body pain. The cardinal finding is the presence of focal areas of hyperalgesia, the tender points. Tender points imply that the patient has a local area of reduced pain threshold, suggesting a peripheral pathology. In general, tender points occur at muscle tendon junctions, a site where mechanical forces are most likely to cause micro-injuries. Many--but not all--FM patients have tender skin and an overall reduction in pain threshold. These latter observations suggest that some FM patients have a generalized pain amplification state. There has been a recent plethora of experimental studies apposite to the pathophysiological basis of both the peripheral and central aspects of pain.

The Pathophysiological Basis for Chronic Pain
The International Association For the Study of Pain (ASP) defines pain as follows: "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." This definition explicitly affirms that pain has both a sensory and an affective-evaluative component, and furthermore acknowledges that it may occur in the absence of obvious visceral or peripheral pathology. To fully understand chronic pain, one must integrate the sensory and affective/evaluative elements of the pain experience. It is equally misguided to focus on the psychological aspects of pain, as it is to address only the sensory component and ignore the affective dimensions. However, for the sake of clarity, each of these two constitutive elements will be considered separately.

The Sensory Component
Pain is generally envisaged as a cascade of impulses that originates from nocioceptors in somatic or visceral tissues. The impulses travel in peripheral nerves with a first synapse in the dorsal horn and a second synapse in the thalamus, and end up in the cerebral cortex and other supraspinal structures.

This results in an experience of pain and the activation of reflex and later reflective behaviors. These reflex and reflective behaviors are aimed at eliminating further pain. The expectation is that this nocioceptor driven pain will be successfully abolished, allowing healing and a return to a pain-free state. The problem with chronic pain is that the linear relationship between nocioception and pain experience is inappropriate or even absent, and the expected recovery does not occur.

It is a common misconception to view the nervous system as being "hard-wired"; that is, stimulation of a nerve ending (say a needle prick) always produces the same behavioral and affective response. This concept implies that the same intensity of pain stimulus will always elicit the same degree of nerve stimulation and hence the same subjective experience of pain. It is now understood that the concept is wrong. Some 30 years ago, Melzeck and Wall proposed that pain is a complex integration of noxious stimuli, affective traits, and cognitive factors. In other words, the emotional aspects of having a chronic pain state and one's rationalization of the problem may both influence the final experience of pain. Mendell and Wall provided the first experimental evidence that the nervous system was not hard-wired in 1965. They noted that a repetitive stimulation of a peripheral nerve, at sufficient intensity to activate C-fibers, resulted a progressive build-up of the amplitude of the electrical response recorded in the second order dorsal horn neurons. If the system had been hard-wired, each stimulus would have elicited the same response in the second order neuron. They termed this phenomenon "wind-up." It is now appreciated that the phenomenon of wind-up is crucial to understanding the problem of chronic pain via the mechanism of "central sensitization."

Central sensitization refers to an increased activation of second order neurons in the spinal cord, resulting from injury or inflammation-induced activation of peripheral nocioceptors. Sensory input from muscle, as opposed to skin, is a much more potent effector of central sensitization. This may be the clue to the role of muscle pain in the total spectrum of fibromyalgia. A common example of central sensitization is post-herpetic neuralgia. Previous injury to a peripheral nerve leads to an amplification of both nocioceptive and non-nocioceptive impulses. The mechanism responsible for the abnormal perception of non-nocioceptive impulses in post-herpetic neuralgia is an increased excitation of second order nocioceptive neurons in the dorsal horn of the spinal cord. A special example of central pain occurs when there is pathology within the central nervous system. This occurs in a thalamic stroke--severe unilateral pain, often accompanied by strong emotions, that occurs in the absence of any nocioceptive input.

There are two forms of second order spinal neurons involved in central sensitization. (1) Nocioceptive--specific neurons--respond only to nocioceptive stimuli, and (2) Wide dynamic range neurons--respond to both nocioceptive and non-nocioceptive afferent stimuli. Both may be sensitized by nocioceptive stimuli leading to central senitization but wide-dynamic range neurons are generally more intensely sensitized than nocioceptive-specific neurons. Nocioceptive and non-nocioceptive peripheral nerves often converge onto the same wide dynamic range neuron (see figure). Once sensitized by ongoing nocioceptive impulses from peripheral nerves, wide-dynamic range neurons will respond to non-nocioceptive stimuli just as intensely as they did prior to sensitization. This results in sensitizations like a light touch to be experienced as pain (i.e. allodynia). Sensitization of wide-dynamic range neurons by prior pain stimuli provides the pathophysiological foundation for nonnocioceptive pain.

There is emerging evidence that afferent activity from Golgi tendon organs and muscle spindles can be converted into pain signals under the influence of central sensitization. For instance, some patients with strokes and spinal cord injuries develop severe pain on movement. Benc has proposed the term "proprioceptive allodynia" to describe this phenomenon. He describes such individuals as "while not experiencing pain at rest, they develop excruciating burning and tingling, often difficult to describe, that appear only when trying to hold an object, move a limb, stand or walk." Thus everyday muscle activity may cause pain and impair function in some individuals with central sensitization. At a physiological level, pain on movement implies that proprioceptive afferents are projecting onto second order wide-dynamic-range spinal neurons that have been sensitized by previous nocioceptive activity. Thus the central nervous system of subjects who have ongoing pain (e.g. arthritis) or have had previous pain experiences (e.g. post injury pain) may be permanently altered due to changes that can now be understood at the physiological molecular and structural levels. At a clinical level this is seen as persistent pain in survivors of serious illness who experienced high levels of pain during hospitalization, persistent pain after breast surgery, or the occurrence of fibromyalgia after automobile accidents. The reason why the phenomenon of central sensitization only occurs in a minority of individuals is not currently known. At a molecular level, there are many studies demonstrating the important role of excitatory amino acids such as glutamate and neuropeptides such as substance P in the generation of central sensitization. Substance P and CRGP are important neurotransmitters in lowering the threshold of synaptic excitability, which permits the unmasking of normally silent interspinal synapses and the sensitization of second order spinal neurons. Substance P, unlike the excitatory amino acids, can diffuse long distances in the spinal cord and sensitize dorsal horn neurons in spinal segments both above and below the input segment--with resulting pain signal generation from non-nocioceptive afferent activity. Clinically this will lead to an expansion of receptive fields; e.g. the spread of pain from to uninjured areas after an automobile accident.

The Psychological Component
It was seen in the preceding section that chronic pain could occur in the absence of ongoing tissue damage--this is an example of the sensory component of pain. It was also noted that one component of pain is a reflex avoidance behavior that can occur before the conscious appreciation of pain. In terms of brain physiology this implies that more primitive parts of the brain contain several discrete nuclei (e.g. the thalamus, cingulate gyrus, hippocampus, amygdyala, and locus ceruleus) that interact to form a functional unit called the limbic system. This is the part of the brain that subserves many reflex phenomena, including the association of sensory input with specific mood states (e.g. pleasure, fear, aversion etc.). These facts form the physiological basis for considering the emotional aspect of pain. Interestingly, the electrical stimulation of the brain during neurosurgical procedure does not induce pain sensations in pain-free subjects. However, in past pain patients it often reawakens previous pain experiences. It is surmised that such stimulation re-activates cortical and subcortical pain circuits that were previously dormant. It is not known whether there is a single cortical structure that subserves pain memory. Currently it appears that different cortical and subcortical structures are involved in the pain experience. For instance, removal of the somatosensory cortex does not abolish chronic pain, but excision of lesions of the anterior cingulated cortex reduces the unpleasantness of pain. The anterior cingulated cortex is involved in the integration of affect cognition and motor response aspects of pain and exhibit increased activity on PET studies of pain patients. Other structures involved in cortical pain processing include the prefrontal cortex (activation of avoidance strategies, diversion of attention and motor inhibition); the amygdala (emotional significance and activation of hypervigilance); and the locus ceruleus (activation of the "fight or flight" response).

All these structures are linked to the medial thalamus, whereas the lateral thalamus is linked to the somatosensory cortex (pain localization). One example of limbic system activation is the hypervigilance that accompanies many chronic pain states, including fibromyalgia.

The emotional component of pain is multifactorial and includes past experiences, genetic factors, generals state of health, the presence of depression and other psychological diagnosis, coping mechanisms, and beliefs and fears surrounding the pain diagnosis. Importantly, thoughts as well as other sensations can influence the sensory pain input to consciousness as well as the emotional coloring of the pain sensation. The term given for this modulation of pain impulses is the "gate control theory of pain." Thus thoughts (beliefs, fears, depression, anxiety, anger, helplessness, etc.), as well as peripherally generated sensations, can both dampen or amplify pain. Indeed, in many chronic pain conditions (that lack any effective therapy for the sensory/pain component), a reduction of pain and the resulting suffering can only be affected by modulating the psychological aspects of pain. As the psychological contribution to pain varies enormously from patient to patient, this approach has to be individualized. However, there are some general principles that are worth noting. There are important consequences of having pain that will not go away (as is the expected experience for most pain in most people). The unsettling realization that the problem may well be life-long generates a varied mix of emotions and behaviors that are often counterproductive to coping with a chronic problem. Many of these changes (which are partly reflex in origin) would be appropriate for dealing with acute self-healing pain events, but become a liability when dealing with chronic pain. The end result of chronic pain is often depressive illness, marital discord, vocational difficulties, chemical dependency, social withdrawal, sleep disorders, increasing fatigue, inappropriate beliefs, and a radical alteration in their previous personality. Varying degrees of functional disability are a common accompaniment of chronic pain states. The reasons for dysfunction are multiple and vary from individual to individual. Pain often monopolizes attention (causing lack of focus on the task at hand). It is usually associated with poor sleep (causing emotional fatigue). Movements may aggravate pain (causing a reluctance to engage in activity). Fear of activity often leads to deconditioning (which predisposes to muscle and tendon injuries and reduced stamina). Pain causes stress, which may result in anxiety, depression, and inappropriate behavior (causing disability due to secondary psychological distress). The modern era of psychological imaging is providing an important new framework for understanding these "emotional" responses

Newly Diagnosed Patient

Fibromyalgia (fi-bro-my-AL-ja) is a very common condition of widespread muscular pain and fatigue. Seven to ten million Americans suffer from fibromyalgia (FM). It affects women much more than men in an approximate ratio of 20:1. It is seen in all age groups from young children through old age, although in most patients the problem begins in their 20s or 30s. Recent studies have shown that fibromyalgia occurs worldwide and has no specific ethnic predisposition.

The Symptoms of Fibromyalgia

Fibromyalgia patients have widespread body pain which often seems to arise in the muscles. Some FM patients feel their pain originates in their joints. Pain that emanates from the joints is called arthritis; extensive studies have shown FM patients do not have arthritis. Although many fibromyalgia patients are aware of pain when they are resting, it is most noticeable when they use their muscles, particularly during repetitive activities. Their discomfort can be so severe it may significantly limit their ability to lead a full life. Patients can find themselves unable to work in their chosen professions and may have difficulty performing everyday tasks. As a consequence of muscle pain, many FM patients severely limit their activities including exercise routines. This results in their becoming physically unfit, which eventually makes their fibromyalgia symptoms worse.

In addition to widespread pain, other common symptoms include a decreased sense of energy, disturbances of sleep, and varying degrees of anxiety and depression related to patients' changed physical status. Furthermore, certain other medical conditions are commonly associated with fibromyalgia, such as: tension headaches, migraine, irritable bowel syndrome, irritable bladder syndrome, premenstrual tension syndrome, cold intolerance, and restless leg syndrome. Patients with estalished rheumatoid arthritis, lupus (SLE), and Sjogren's syndrome often develop FM during the course of their disease. The combination of pain and multiple other symptoms often leads doctors to pursue an extensive course of investigations, which are nearly always normal.

Diagnosing Fibromyalgia

There are no blood tests or X-rays that show abnormalities diagnostic of FM. This initially led many doctors to believe that the problems suffered by FM patients were "all in their heads," or that fibromyalgia patients had a form of masked depression or hypochondriasis. Extensive psychological tests have shown these impressions were unfounded. A physician's diagnosis of FM is based on taking a careful history and the finding of tender areas in specific areas of muscle. These locations are called "tender points." They are tender to palpation and often feel somewhat hardened if the muscle is stroked.

The Long-Term Outcome for Fibromyalgia

The musculoskeletal pain and fatigue experienced by fibromyalgia patients are chronic problems that tend to have a waxing and waning intensity. There is currently no generally accepted cure for this condition. According to recent research, most patients can expect to have this problem lifelong. However, worthwhile improvement may be obtained with appropriate treatment. There is often concern on the part of patients, and sometimes physicians, that FM is the early phase of some more severe disease, such as multiple sclerosis, lupus , etc. Long-term follow-up of fibromyalgia patients has shown that it is very unusual for them to develop another rheumatic disease or neurological condition.

However, it is quite common for patients with "well-established" rheumatic diseases, such as rheumatoid arthritis, systemic lupus, and Sjogren's syndrome, to have fibromyalgia also. It is important for these patients' doctors to realize they have such a combination of problems, as specific therapy for rheumatoid arthritis and lupus, etc. does not have any effect on FM symptoms. Patients with fibromyalgia do not become crippled with the condition, nor is there any evidence it affects their lifespan. Nevertheless, due to varying levels of pain and fatigue, there is an inevitable contraction of social, vocational, and avocational activities that leads to a reduced quality of life. As with many chronic diseases, the extent to which patients succumb to the various effects of pain and fatigue are dependent upon numerous factors, in particular their psycho-social support, financial status, childhood experiences, sense of humor, and determination to push on.

The Treatment of Fibromyalgia

The treatment of FM is frustrating for both patients and their physicians. In general, drugs used to treat musculoskeletal pain, such as aspirin, non-steroidals (e.g. ibuprofen), and cortisone, are not particularly helpful in this situation. As in any chronic pain condition, education is an essential component that helps patients understand what can or can't be done as well as teaching them to help themselves.

It is important for a patient's physician to discover whether there is a cause for sleep disturbances. Such sleep problems include sleep apnea, restless legs syndrome, and teeth grinding. If the cause for a patient's sleep disturbance cannot be determined, low doses of an anti-depressive group of drugs, called tricyclic anti-depressants or short acting sleeping medications such as zolpidem (Ambien) may be beneficial. Patients need to understand these medications are not addictive when used in low dosages (eg., amitriptyline 10 mg at night) and have very few side effects. In general, routine use of sleeping pills such as Halcion, Restoril, Valium, etc., should be avoided as they impair the quality of deep sleep. It is claimed that Ambien (zolpidem) avoids this problem.

There is increasing evidence that a regular exercise routine is essential for all fibromyalgia patients. The increased pain and fatigue caused by repetitive exertion makes regular exercise quite difficult. However, those patients who do develop an exercise regimen experience worthwhile improvement and are reluctant to give up. In general, FM patients must avoid impact loading exertion such as jogging, basketball, aerobics, etc. Regular walking, the use of a stationary bicycle, and pool therapy utilizing an Aqua Jogger (a floatation device that allows the user to walk or run in the swimming pool while remaining upright) seem to be the most suitable activities for FM patients. Supervision by a physical therapist or exercise physiologist is of benefit wherever possible. In general, 20 minutes of physical activity three times a week at 70% of maximum heart rate (220 minus your age) is sufficient to maintain a reasonable level of aerobic fitness.

Drugs such as aspirin and Advil are not particularly effective and seldom do more than take the edge off FM pain. Opioid analgesics (propoxyphene, codeine, morphine, oxycodone, methadone) may provide a worthwhile pain relief in a subgroup of severely afflicted patients, but fibromyalgia patients seem especially sensitive to opioid side effects (nausea, constipation, itching, and mental blurring) and often decide against the long-term use of these drugs. The use of opioid analgesics (narcotics) in the management of non-malignant pain has been a controversial issue for many doctors, with the usual reasons for concern: addiction, oversight by state medical boards, and criminal diversion of drugs. However, recent research has shown that addiction seldom occurs when these medications are use in chronic pain states. It is important to understand the difference between addiction and dependence (which occurs with all these drugs in the majority of patients (see Addiction/Dependence). Two particularly useful weak opioids in the management of FM pain are tramadol (Ultram) and the combination of tramadol with acetaminophen (Ultracet). Neither of these two medications is a FDA scheduled drug (i.e. they have minimal addiction potential).

Particularly painful areas often may be helped for a short time (2-3 months) by trigger point injections. This involves injecting a trigger point with a local anesthetic (usually 1% Procaine) and then stretching the involved muscle with a technique called spray and stretch. It should be noted the injection of a tender point is quite painful (indeed, if it is not painful the injection is seldom successful). After the injection, there is typically a lag of two to four days before any beneficial effects are noted. Other techniques that directly help the tender areas on a transient basis are heat, massage, gentle stretching, and acupuncture.

About 20 percent of FM patients have a co-existing depression or anxiety state that needs to be appropriately treated with therapeutic doses of anti-depressants or anti-anxiety drugs often in conjunction with the help of a clinical psychologist or psychiatrist. Basically, patients who have a concomitant psychiatric problem have a double burden to bear. They will find it easier to cope with their FM if the psychiatric condition is appropriately treated. It is important to understand that fibromyalgia itself is not a psychogenic pain problem, and that treatment of any underlying psychological problems does not cure FM.

Most FM patients quickly learn there are certain things they do on a daily basis that seem to make their pain problem worse. These actions usually involve the repetitive use of muscles or prolonged tensing of a muscle, such as the muscles of the upper back while looking at a computer screen. Careful detective work is required by the patient to note these associations and, where possible, to modify or eliminate them. Pacing of activities is important; we have recommended that patients use a stopwatch that beeps every 20 minutes. Whatever they are doing at that time should be stopped and a minute should be taken to do something else. For instance, if they are sitting down, they should get up and walk around--or vice versa.

Patients who are involved in fairly vigorous manual occupations often need to have their work environment modified and may need to be retrained in a completely different job. Certain people are so severely affected that consideration must be given to some form of monetary disability assistance. This decision requires careful consideration, as disability usually causes adverse financial consequences as well as a loss of self esteem. In general, doctors are reluctant to declare fibromyalgia patients disabled and most FM applicants are initially turned down by the Social Security Administration at the first review. However, each patient needs to be evaluated on an individual basis before any recommendations for or against disability are made.

For more details please contact Dr. Ajimshaw @ dr.ajimshaw@rediffmail.com or ajimsha@aimst.edu.my

I am still here........

Hi all,
Now I am in Malaysia. ie in AIMST university of Kedah State. just joined today. it doesnt mean that i have dropped all my interest in MFR and Hands-On techs. still now i am under the work of my book on MFR; a complete version of Practical and theoretical part of MFR with demonstration pictures. I am making it as a very discriptive one with details of all the myofascial trigger points and its signs and symptoms.(I thing there are only a few materials over this). so please give me some time to complete this. during your studies if you have any queries please feel free to contact me.

Aji