Professional Documents
Culture Documents
Your Fibromyalgia
Treating Fibromyalgia
Utilization of
Brought
an
to
Individualized
you
Treatment
by:
Guide
Validation
Self-Management
and
System.
Fibromyalgia-Treatment.com
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Table of Contents
Introduction
Associations
Magazines
10
and Internet
13
Resources
and Journals
14
15
Support
Groups
16
Support
17
Primary
Focus
18
Chapter 2: Reviewing
History
Fibromyalgia
19
and Introduction
19
Demographics
Symptoms
Fibromyalgia
Triggers
20
20
27
Diagnosis...............................................................................................................
27
Causal Theories
29
Chapter 3: Fibromyalgia:
General Confusion
SymptomCause
Negative Feedback
and Confusion
Loops
Medical System
Effective Treatment
Chapter 4: Self-Management:
Overwhelming
Options
Taking Responsibility
Education
- Laying
the Foundation
for Success
30
30
32
32
33
35
37
38
40
40
41
42
43
Take Action
44
Setting Goals
Become
Problem-Solver
Evaluating
Treatment
Options
Self-Empowerment
Self-Management
Conclusion
What
you
need to know
Medical Specialists
Create
Partnership
FDA-Approved
with
your
Physician
Pharmaceuticals
45
46
47
49
50
51
51
55
57
Antidepressants
59
Prescription
60
Anti-Anxiety
Sleep Medications.............................................................................
Medications
Pain Management..................................................................................................
Coping Strategies
Dietary
for Pain
Supplements
60
61
63
63
Diet
. . . ..................................................................................................................
........................................................
. . . . . . . . . . . ...........................................................................................................................
. . . . . . . . . . . . . . . . . . . . . ..................................... ... ... ... ... ... ... ... ...
. . ...........................................................................................
.......................................................
Exercise
Therapies
A Systematic
Approach
Tools
Tracking Symptoms
A Concept and
System
"FibroTrack"
FibroTrack:
Internet
Enhanced
Disclaimer
Self-Management...............................................
66
67
68
70
75
77
77
78
79
80
81
82
85
--------------------------------------------------
Introduction
Iam not
nor a
medical practitioner
project
some aura
Fibromyalgia
havoc
on
in
of authority
has undermined
the lives of
my
my
passionate
my
love
about fibromyalgia?
our
lifestyle
are
they
for
about. Am I
Ipassionately
years.
Iqualify
extraordinary
family aboard
as we both fought
as an expert in how
feelings
typical sort of
our
heads that
our
we
kids and
- we fought
reality. Ipurchased
dream
my
passionate
destroy.
move our
something
Absolutely!
and hopelessness
can
fibromyalgia
live
on
of helplessness
could
our
the
pregnancy
fibromyalgia.
our
was
My wife Michele
with fibromyalgia
on
pay
- our
my
focus remained
on
researching
running
our
small
company
many
many
insurance
so we could
with a very
in
and implementing
business
was
corner
our
Through 2008
we
as our
also increased
We both believed
simple
tropical paradise
the
war
against fibromyalgia.
care
success,
If youre
up
a fibro
we went all-in.
expensive,
our
pay
off. Michele
locations"
We began seeing
being extremely
going to be
living aboard
moved aboard
problems
- we
and if it didn't,
we
But
was
worse.
dream.
specialist
plan
had been turned only to feel crushed again when things got
maintained
steam
we were
is true).
We had adventures
and
we
your
boat in exotic
away from
we
a vengeance,
the "Big Push" medical efforts the fibro began to slowly build back. After
returned
never seen
flared with
Michele into
complete
wreck.
We
were
was
convinced
overwhelming
migraines
something
severe
confused, but
Michele
what
was
new symptoms
one
was
was
really
- the "Cruising
was
and huge
This flare
coupled with
wrong.
watching
my
endeavor
to determine
wife suffer
what
we began dealing with fibro on a new level and working to put our lives back in
some semblance of order, Ibegan to feel a new sense of mission. Iwould focus my
life on helping my wife overcome this disease and provide my family with the rich
As
was to
make myself
reading everything
an expert on
my
that
fibro is
case,
a war, not
Ialso understood
Michele
an
wife. Ihad
every
of treatments
magic combination
are
was
reward
just
that
tempered
as
wonderful
single battle.
that determining
would be
individual
what treatments
an
itself differently
my
and in
success.
Iset
fibromyalgia.
research scientists
expectation
on
and productive
effective
for
manifests
treatment strategy
manage
treatment efforts. Ineeded to be able to not only research what treatment options
were
approach that
we were
multi-faceted
dietary supplements,
developing.
an
approach consisting
The
more
would be
Ilearned, the
more
ongoing individual
of pharmaceuticals,
and alternative
what combination
medicine
was
would be
process.
about self-
on
programs.
an
treatment
Among the
fibromyalgia
difficult.
Ibegan to seek
programs or systems to
utilize in this
process.
of illnesses
so
in general, Iexpected
online
an
facilitating
process.
ongoing
Its
else to determine
it is something
one
This need is what has driven both this ebook and the development
FibroTrack
application.
to do in order to treat
treatments
on
My focus is not
your
will be effective
you
for
telling
probably
you
is to test it. My
improve
your
ability to intelligently
to
suggesting
management
you
what
you
effective
for
to
required
you
treatment
a selfmanage one on an
treatment. What is
How do
This ebook
at
fibromyalgia
program?
ongoing basis?
you
you need
you what
what
to tell
am
of the
specifically
you
fibromyalgia.
do, but
and
processes that Ipresent in this book are not new. Ihave not been
new conceptual research and the processes discussed here are not
new developments. What Ihave done is take existing research data
treatment process suggestions from many different experts and combine them
an overall strategy that can be implemented and managed by those struggling
The concepts
engaged
and
in
revolutionary
and
into
with fibromyalgia.
efforts. But
you
you to
improve
to the FibroTrack
can
your
application
help
any
throughout
patient improve
success.
what
you
you
You will
their self-management
you
without
- please - make
action
never
and
the effort to
yields
a great
deal of relevant
information
about fibromyalgia
Internet.
What is Fibromyalgia?
Also
Finally
Please follow
my
Fibromyalgia
Treatment
Fibromyalgia
Symptoms
Blog.
THANK YOU.
Thank
If
you
have
any
Ihave
suggestions,
that
you
feel Imay
terrycspringer@yahoo.com
-----------------------------------------------------------
10
1:
Chapter
Fibromyalgia
persistent
pain appearing
treatments
can
parameters
frequently
with
of this disorder
are
central to fibromyalgia
our purpose:
This is
confusion
of other possibilities,
throughout
no
on
shortage
is
concluded
be
of
its history.
an
individualized
so
treatment
approach,
can
be
of symptoms.
of information
about fibromyalgia
and its
associations
many
different
and organizations
this topic.
nature. Diagnosis
diagnosis. Confusion
treatment options.
abound
definitive
To develop
There is
and
symptoms
to Knowledge
From Confusion
Getting Started:
so
pervasive
available
that it triggered
of fibromyalgia
websites
an
online
our
website,
direction.
Books
There have been hundreds
Below
are
if not thousands
of books published
on
fibromyalgia.
10
11
The Complete
By:
Lynne Matallana
Ph.D,
with
Laurence
A. Bradley
MD, Muhammad
Stuart Silverman
Yunus
MD
a great
This is
information
developing
program.
book.
It
covers a
diverse battery of
a care-provider team,
you can take to move your
on
of
a self-management
covers many treatment
and implementing
actions
and
From Fatigued
By:
to Fantastic
Jacob Teitelbaum
MD
information
goes
presented
treatment options,
overwhelming.
so
mandatory
- the amount
of
on a
much
so
that it
can
be
someone
complicated
to digest. Teitelbaum
develop
an
does focus
individualized
while he is overwhelming
on
on
treatment
can
is
be difficult
the need to
protocol, but
are recommended, he is
any shortcomings though,
the management
process.
Despite
information.
11
12
Fibromyalgia
for Dummies
an
This is both
beginners
seasoned
excellent
a great
and
reference
relative to different
background
related to fibromyalgia,
reader gains
struggles
solid understanding
and the
of the
accepted
by the medical
One shortcoming
on the need
processes. The
in this book is
management
book documents
wealth of information
discussions
it's
about treatment
worthwhile
Fibromyalgia
into
an
source.
Pain
covers a
largely textbook
about Myofascial
very
huge amount
manner.
style
pain is covered in
co-
This
relationships
associated
to integrate treatments
management
on any
and
with different
treatment
comprehensive
related
processes.
are
content
excellent.
12
13
Associations
and Internet
resources are
Considerable
multitude
of information
professional
associations
Fibromyalgia
now
on
and Chronic
organization
awareness
to increasing
of
Pain Association
nonprofit
to fibromyalgia
and advocating
fibromyalgia
Resources
available
dedicated
(NFMCPA)
Association
with fibromyalgia
and other chronic pain illnesses. Their mission is to educate patients, the medical
the public, government,
community,
timely diagnosis
and appropriate
conditions. NFMCPA
on
information
Fibromyalgia
advocacy
regarding
and members
and overlapping
that
can
with
American
Academy
yearly conference
educational
number of online
provide information
sufferers
Pain Foundation
of Pain Management
on
pain, known
opportunity
access to a
as
wealth of
including e-newsletters,
conditions,
as
well
forums, general
as
research and
to fibromyalgia
patients (www.fmaware.org)
resources
still available.
(www.aapainmanage.org).
PAINWeek,
of
and overlapping
have
fibromyalgia
Other organizations
the importance
is donor-supported,
and Chronic
on
information
and scientists
an
as an
and the
In addition,
interest in pain
management.
A number of Internet-based
fibromyalgia.
online
In addition to
resource
fibromyalgia
Co-cure
(www.co-cure.org)
as
well
patients, including
and
comprehensive
Foundation
is
an
the
daily newsletter,
review of additional
industry-sponsored
group
large repository
information.
from
for both
as message
Oregon Fibromyalgia
researchers
doctors,
helpful information
www.immunesupport.com
contains
of
Finally, the
fibromyalgia
(www.myalgia.com).
13
14
Magazines
and Journals
magazine
Fibromyalgia
registered
members.
Fibromyalgia
covers
and advocacy
and newsletters
and support to
and Chronic
are
Back issues
Network,
The NFMCPA
journal (Fibromyalgia
an
alternative
fibromyalgia
are
Network
devoted
Fibromyalgia
providing
Fibromyalgia
sufferers.
Alternative
causes
quarterly
News is
of
non-
by the
Other periodicals
such
as
that
Womens
information
women, as
information
that
both
eNews pertaining
Coalition International.
be of interest to fibromyalgia
for free to
profit organization
may
on
for download
patient-advocacy
health magazine
their bi-monthly
are a
provide, there
publishes
member-supported
quarterly
these organizations
consumers.
well
for
prevent disease.
In the academic
world,
fibromyalgia-related
number of scientific
information
journals
regularly
publish
or
muscle inflammation
is not
(like
diseases
do), it
covers
information
Rheumatology,
fibromyalgia.
and
Clinical Rheumatology,
pain management
College of Rheumatology,
regularly
Rheumatology.
publish findings
such
as
and
focused
on
of
14
15
Fibromyalgia
are
rheumatologists
commonly
or
rheumatic
consulted
the symptoms
and Therapists
form of arthritis
during
of fibromyalgia
as a
condition)
continues
physicians
can
can
neurological
one
are an
and Depression
becoming
part of
important
occur
manage the
an
effort to increase
In addition, psychotherapists
psychological
to administer
providers
difficulty
licensed
normal activities
as acupuncture,
supplements,
depression,
to fit
healthcare
therapeutic
are
in
trained
specifically
healthcare
and independence
massage
by
needs.
through
and alternative
an
integrated
therapies
(such
and
and regular exercise. For those patients who suffer from anxiety and
tailored psychotherapy
is also crucial.
discussions
your
more
be of great
exercise
massage,
also licensed
Learn
and
therapy, complementary
and
providers
therapists
to regain functioning
patients
and treatment
chiropractic,
can
therapists
electrical stimulation
management
system of pharmaceutical
of the disease.
of illnesses
ramifications
the environment
It is important
effective
are
performing
modifying
plan.
components
psychological
care
patients
fibromyalgia
flexibility
understanding
rheumatological
with fibromyalgia,
more
to do
specialist
increasingly
as our
of fibromyalgia,
commonly
similar to those of
are
also diagnose
and psychologists
is
quest to achieve
are
of the muscular-skeletal
and management
Anxiety
so.
of fibromyalgia
about building
about
individual
Medical Specialists
care team
is covered in
in Chapters
in the treatment
4 and 5.
of Fibromyalgia.
15
16
Support
Groups
Participation
be of
support
in fibromyalgia
also
patients to connect with others who have the disease and gain valuable insight that
can
overcome
help
changes
challenges
fibromyalgia.
Others
may
unevenly
focus
on
distribute
related
environment
of the lifestyle
groups
Support
of information
in tone, with
discouraging
their understanding
of fibromyalgia.
the exchange
to understand
It is important
and improve
diagnosis
also offer
to treatment
can
groups are
the
the negative
member
same.
Some
may
be
aspects of
participation,
with
one or
two individuals
is important
dominating
for
A few examples
of the
numerous
available
include:
www.dailystrength.org
www.mdjunction.com/fibromyalgia
www.fibrotalk.com
www.livingwithfibro.org
The Arthritis
across
support
Foundation
sponsors
can
group
The NFCPA
directory
fibromyalgia
find
directory
(www.fmcpaware.org/support-groups),
interested
support
of these
of support
organized
groups
by state. Individuals
who
are
in starting
to register
one
well
as
16
17
Support
Support
groups can
provide camaraderie
as mere
for fibromyalgia
motivated
patients, however
convene to
where patients
clubs
groups
they
commiserate
individuals
toward achieving
on
collective
foxhole, support
group
members
are
review
symptoms, and
group
to each other. Like soldiers in a
war against fibromyalgia together.
They should hold each other accountable, as accountability has demonstrated
effectiveness in helping people achieve a variety of goals, and it can also help
patients progress toward reducing fibromyalgia symptoms as well.
maintain motivation
support
successful
is
in this
The FibroTrack
online self-
management
includes
focused
system
many tools
on assisting
those with
in
fibromyalgia
building and
participating
an
in
effective,
meaningful
support
includes
online
group.
a
sophisticated
This
system
(age, geographic
symptoms).
networking
group
members
also facilitates
support
on
based
FibroTrack
their demographic
conditions
group
up to promote
The information
presented
our
an
data
and Fibromyalgia
interaction
with social
and treatment
program
support
groups.
overview
of the highlights
website, www.fibromyalgia-treatment.com
of
more
more.
for
17
18
Primary
Focus
to
do it! Information
available
Step 1:
abounds
on
Learn.
Knowledge
is the foundation
articles
following
required
to get
Current
Diagnostic
The Diagnostic
Criteria
Process
of effective
Diagnostic
History
Multiple Diagnosis
action.
The
of knowledge
of Fibromyalgia
and Fibromyalgia
Fibromyalgia
Medical Tests
Fibromyalgia
Causal Theories
Brain Chemical
Fibromyalgia
and Genetics
Anxiety
Abnormalities
and Fibromyalgia
Fibromyalgia
Widespread
Demographics
Fibromyalgia
Myths
of Fibromyalgia
Pain
Online Self-Management
Symptoms
Internet
Online
vs
Overview
Offline Treatment
Enhanced Treatment
Treatment
Focus: Symptoms
Perspective
Efforts
or
Causes?
18
19
2:
Chapter
History
Reviewing
Fibromyalgia
and Introduction
First observed
and fibrositis
muscular
rheumatism.
syndrome. It later
pain
across
referred to
(such
as
is diagnosed
areas on
19 specific
symptoms
associated
was
century, fibromyalgia
in the nineteenth
fibrositis
by examining
as
the body,
to refer to
as
well
dysfunction,
and
fatigue).
years,
Over the
has carried
fibromyalgia
many
clinicians
believed
combination
it
an
in the absence of
community
psychosomatic
simply imagined
was not a
definitive
finally received
by the medical
diagnostic
the credibility
it deserved
and
gave
patients the
clinicians
were
is
a true
has become
more
care
they
or
some in
as a true
from
so
the
desperately
greatly deserve.
please refer to
our
and Fibromyalgia
the
many aspects
of
website www.fibromyalgia-treatment.com.
Treatment
some
condition
resistance
widely accepted
so
criteria,
ability to receive
sections
disease,
established
need and
singular
of related conditions. In
symptoms
itself
a group
from
many
stigma within
as a
disregarded
that fibromyalgia
of symptoms
illegitimate
legacy of negative
Originally
Symptoms
is Fibromyalgia?,
contain comprehensive
The
Fibromyalgia
information
articles detailing
19
20
specific treatment
and alternative
drugs to complementary
therapies
detailed articles
on
the
anxiety, depression,
fibromyalgia.
Demographics
Although fibromyalgia
discriminate.
survey
by
a team
were
were
moderately
incomes
overweight.
Caucasian. The
researchers,
in conjunction
Association,
were
it does not
of leading fibromyalgia
96.8%
women,
Anyone, including
conducted
of fibromyalgia.
Symptoms
Pain
The most
common symptom
widespread
as
associated
with fibromyalgia
as
tissues (myofascial
by far is chronic,
pain).
pain
as
Individual descriptions
well
of
pain sensations
aching,
tingling sensation.
Points
on
causes
may continue to
may feel constantly
with fibromyalgia
the body
sufferers
to ache all
ache regardless
overworked.
over.
Certain
of the therapies
The pain of
can concentrate around the joints of the neck, back, shoulders, and
hips, which can make sleeping difficult and restrict mobility. Furthermore,
fibromyalgia pain is frequently made worse by changes in weather, temperature,
loss of sleep, fatigue, excessive physical activity or lack thereof, and stress/anxiety.
fibromyalgia
Fibromyalgia
resolves
over a
as
with
suddenly
and
20
21
and interacts
severely
sleep deprivation
Chronic
and daytime
maintain
with
an
pain
individuals
results in increased
fatigue. Fibromyalgia
an
is extremely
can
to
for sufferers
active lifestyle
and anxiety.
Fatigue
In addition to widespread
can
patients and
symptom of fibromyalgia.
another hallmark
so severe
be
It
occurs
in
as many as
fatigue is
90% of
and anxiety.
Many fibromyalgia
Some researchers
fatigue
seen
and physicians
in fibromyalgia
have observed
strong similarities
between the
(CFS). CFS is
similar symptoms
and fibromyalgia
in the
same
are
often miss-diagnosed
as
each
patient.
Sleep Impairment
Impaired
- 90%
groggy
and un-refreshed
difficulty
initiating
excessive
daytime
or
Fibromyalgia
an
individual
a state
85%
or
of
poor
report
quality, and
apnea
is also
cause a shift
in poor sleep
as many as
frequently
results when
with
individuals
and non-restorative
awakening.
maintaining
sleepiness.
as
activity known
upon
common, and it
pauses in breathing
quality and
next day.
21
22
Morning Stiffness
as
pain, tenderness,
report waking
with fibromyalgia
becoming
can
activity, making
even
up or
of morning stiffness
particularly
as
for fibromyalgia
patients.
upon awakening,
range of motion in
your
may
and limit
difficult
with
warm up before
with mobility
interfere
up
stiffness
the
Tender Points
one
Historically,
receive
diagnosis
was
fibromyalgia
presence
of the
criteria to
required
of
the
of at least 11 of
sites
these
physician
pressure
throughout
the
pressure,
light
patients
with fibromyalgia
feel increased
pressure
The
may
that is disproportionate
to the amount of
that is applied.
presence
diagnosis
of myofascial
of fibromyalgia.
trigger
points
can
sometimes
complicate
the
22
23
tissue surrounding
are
as
known
as
can
negative
significant
worsens over
difficulty
impact
misdiagnosed
as
on an
individuals
fibromyalgia
and vice
versa.
times
Trigger points
diagnostic
underlying
requirement
pressure
is applied, but
no
hard muscular
may
be
to understand,
are a
present in
myofascial
and disproportionate
knots
and
have
the underlying
is typically
tenderness
pain
can
active lifestyle. As
What is important
pain syndrome
are
tender points
as
an
pain syndrome
for fibromyalgia.
myofascial
result in stiffness
pain syndrome
ability to live
features, myofascial
myofascial
time, and
myofascial
an
trigger
pain when
are present.
Headaches
The majority
experience
headaches. Migraine
Cognitive
Impairment
Individuals
headache
/ Fibro
medicines.
Fog
impairment,
characterized
a symptom so prevalent
by memory loss (both
frequently
difficulty
maintaining
focus and paying attention, and trouble locating the right words to speak while
impairments,
fibromyalgia
patients
and disorientation.
may
also
These
23
24
cognitive
difficulties
are
very
all
patients and
can
fuel
& Anxiety
Depression
While
many
may
depression
fibromyalgia,
disturbances,
up to
goes
often
some
- actions
activity
hand-in-hand
fatigue associated
by constant
can
in fibromyalgia
and fibromyalgia
excessive
it
can
and sustained,
it
can
fibromyalgia
as a
that
very severe
can
with depression.
when
symptoms
no
also
elevated
stimulus
social
a natural response of
occurs under normal
Anxiety is
become
debilitating
anxiety disorder
many
condition
accompany
and
quality
marked by sustained
generalized
swallowing,
Irritable
with
sleep
sufferers
even
be beneficial
be
have decreased
the human body to stress, both good and bad. When anxiety
circumstances
headaches,
Anxiety
at
also be exaggerated
to be present in
is estimated
depression
fibromyalgia
feelings of inadequacy.
Bowel Syndrome
most
24
25
When compared
fibromyalgia
researchers
have estimated
Up to two-thirds
that
Interstitial
Cystitis
Interstitial
cystitis (IC) is
vary
as
from
person to person
pain
and
or discomfort
may increase
may also
may worsen during
symptoms
menstrual
periods
conditions
such
the bladders
Secondary
symptoms
of Fibromyalgia
A number of secondary
from patient to patient
comprehensive
symptoms
so
are
associated
with fibromyalgia.
list. An abbreviated
list of
some
of the
They
to provide
vary
is
below:
Temporomandibular
and tenderness
TMJ
can
also manifest
itself
as
on
TMJ is characterized
by pain
ear,
ears.
difficulty
or as a
are women
Restless
RLS is characterized
urge to move
between the
ages
of 30 and 50.
by the uncontrollable
25
26
occur
generally
arms may
describe
the sensations
eyes:
as
aching,
used by
many
are
patients,
Abnormally
Many fibromyalgia
make sleeping
some
patients experience
as
well
as
even more
increase
difficult
pain.
as
experienced
eyes
can
These symptoms
fibromyalgia
are
sort of skin-related
tingling
report dry
fibromyalgia
antidepressants,
or
crawling,
with fibromyalgia
these symptoms
or
Many individuals
leg, feet,
creeping,
their symptoms
upper
problems
are more
Increased
experience
Vulvodynia:
which is
Many
throbbing. It
can
women
with fibromyalgia
condition characterized
pain is generally
described
can
be constant,
Endometriosis:
as
also be marked by
or
it
can come
and
grows
vulvodynia,
also experience
burning,
cavity
are more
causes severe
system. Endometriosis
of
may cause
infertility.
Hypoglycemia:
Many individuals
hypoglycemia,
or
sugar
low blood
with fibromyalgia
sugar.
The symptoms
also experience
associated
sweating,
26
27
Fibromyalgia
The exact
potential
Triggers
cause
causes
development
as
of fibromyalgia,
families. In addition,
many
may
Genetic factors
play
indicate
are
individuals
causal association
with fibromyalgia
potential triggers
obese,
an
many
observation
people with
may
which also
No definitive
evidence
In
as
individuals.
number of
role in the
causes, a
predisposed
or
often overweight
to cluster in
of fibromyalgia
among
of fibromyalgia
include: accidents
that result
in physical trauma, physical and/or sexual abuse, illness, high stress levels,
childbirth, and others.
Diagnosis
Fibromyalgia
diagnosis
rule out
is
very
difficult
through the
process
condition that is
is often achieved
number of conditions
and frustration
and undergo
multiple
of elimination.
for patients,
as
one
to another
specialist
procedures.
fibromyalgia
ruling
out the
clinical
features
rheumatoid
generalized
experience
in particular
and
to
characteristic
arthritis
abnormalities
widespread
blood
each
joint
condition.
swelling,
tests. Patients
inflammation,
presence of certain
as many fibromyalgia
more
difficult,
findings
is easily done,
when evaluated
in the diagnosis
as most
when
report
and
with
specific
with
in specific
rashes,
blood
can prove to
feeling
the exclusion
patients
neurological
occurs
patients
present
conditions
may
ultimately
fibromyalgia
using standard
of fibromyalgia
example,
deformities,
abnormalities
neurological
patients
and
For
joint
with lupus
be
numbness,
of neurological
do not show
any
abnormal
attempting
to distinguish
it from
27
28
other
chronic
in
pain
functional
syndrome.
fatigue
as many as
patients
also
as
diagnosis,
physician
80%
have
of
such
may vary,
interpretation
minimum
symptoms: decreased
as
These included
well
presence
much-needed
are very
70%
to diagnose
one
of
of mis-
subjective
and
disease
presence
revised,
more
in
formal set
for
response to symptoms,
weather-related
of chronic widespread
recognition
co-occur
to fibromyalgia
College of
gave
differently.
anxiety, headaches,
(ACR) established
the
the
to
fibromyalgia
40%
high frequency
physicians
which required
as
is
of
and
stress/anxiety-related
fatigue/tiredness,
Rheumatology
presence
physical activity in
symptom aggravation,
disturbances,
some
symptoms
fibromyalgia,
of three months
70%
leading
syndrome,
Approximately
of criteria to diagnose
bowel
approximately
syndrome.
associated
irritable
the symptoms
2) non-refreshing
TMJ,
whereas
bowel
Moldofsky
as
patients,
irritable
patients
fibromyalgia
disorders,
as an
minimum
of 11 of
effort to standardize
the symptom-based
physicians
are
using the
28
29
It
was
worded in
a way
are
on an
based
11-point numeric
on a
originally
used
assessments
was
100 millimeter-long
the questionnaire
deficiencies,
slash
score.
patients to place
fibromyalgia
first published
environmental
was
to
Impact
patients. Developed
difficult
visual
line to
was
about
and symptoms.
Causal Theories
reasons
years of
that fibromyalgia
transmits
and
processes
is
so
cause
is the
theory that
with fibromyalgia
Research suggests
that this
for pain signals to reach the brain, which then relays the painful sensation
levels of pain-regulating
researchers
to hypothesize
individuals
may
studies in fibromyalgia
genetic
cause
genome
are
for clues
some
eight times
more
likely to
on
observational
relatives, researchers
have turned
as to
Based
of fibromyalgia.
for
in the brain.
for fibromyalgia.
brains
no
possible
back to
patients have
In addition, relatives
suggestive
neurotransmitters.
what
In particular,
the
interest to researchers.
29
30
3:
Chapter
Fibromyalgia:
leaving
you
is relentless. It
can
wrack
your
exhausted
it manifests
itself
presents
Fibromyalgia
posed by fibromyalgia
and struggles
care
on
our
perceptions
Americans
we
have
of
come to
medical system.
General Confusion
Fibromyalgia
symptoms
years,
is difficult
and co-morbid
is often misdiagnosed
conditions
discounting
patients
that
symptoms
accompany
many
a whiners
was all in the
head.
fibromyalgia
and suggesting
to be
their pain
disease,
(that
Treatment
and confounding
of fibromyalgia
is highly individualized;
understanding
treatment strategies.
there is
no
Magic
Pill that
everyone. What works for one patient may be totally ineffective for
may even make that patients symptoms worse. Unfortunately, those
are helped to a great extent by a particular therapy may celebrate the relief of
30
31
their symptoms
surrounding
in the
case
of fibromyalgia,
symptoms
friends, co-workers,
crushing and
can
even
peoples
creates
negative
with fibromyalgia,
negative
attitudes
attitudes
new
fibromyalgia
negative
or even
condescending.
associated
trigger
perpetuating
treatments.
about effective
confusion
unintentionally
even
feedback
health
care
providers
can
and
can
are
be
from
be
loops.
31
32
stop individuals
is that there is
no cure.
Unfortunately,
are
fibromyalgia
are
diagnosed
Additionally,
with fibromyalgia
there is
clinical conditions
is
with true
Many individuals
at the
In addition, there is
no
on a
recognized
even
percentage
significant
and accepted
have
negative
reality
impact
point cannot be
enough: What may work for one patient may not work for another,
may in fact make the other patient feel worse! This reality makes the Elusive
a moving target, and the weapons for fighting him inconsistent from one
emphasized
and
Fiend
warrior to another.
SymptomCause
Interplay
are
and Confusion
of
of fibromyalgia
can cause
can cause
depression
anxiety. Fatigue
depression.
Sleep problems
can cause
fatigue. Deep,
persistent
pain
can cause
can
be both caused
can cause
occur. These
by stress and
stress to
symptoms
come
and
wane,
also frequently
go, or
fibromyalgia
pinpoint
wax and
in seemingly
fashion. As the
what
random
course
came
of
over
unfolds
first in different
develops
symptom /
which
can
extremely
cause
difficult
for patients to
loops. In effect,
make determining
effective
chicken
approaches
32
33
can
to understand.
can
They
Determining
the patients
by
be
extremely
the relationship
more
complicated
The
manner
are no
there
complicated
and difficult
cycle, weather,
and environmental
than calculating
clinical standards;
are
factors.
symptoms
rocket trajectory
prove to
confusion
life.
are
relationships
be impacted
on
impact
lead to increased
the
everyones
same
for
NASA
often
moon
for everyone! In
fibromyalgia
will be different
key
can
for
you
is unique.
than it is for
others.
Learn
more
Anxiety
Stress
Negative
Feedback
causal symptoms
Depression
Fatigue
Sleep
Loops
Many symptoms
associated
with
fibromyalgia
are not
negative
manner.
known
as a
This
type of relationship
is
negative
feedback
loop. Negative
feedback
can best be
as a cycle in
described
which
an event
leads to
so on.
until something
happens
an
33
34
individual
may
with fibromyalgia
sleep adequately
aggravates
results in excessive
the persistent
fibromyalgia.
experiences
to
This inability
fatigue
from their
may not
be able to sleep
that incorporates
the
excess
Causal symptoms
sleep quality.
negative
loops
feedback
Furthermore,
the interaction
to overlapping
scenario
of negative
may cause
a
NOT by definition
symptoms
debilitating
can,
downward
to
worsen over
is
in frequency
fibromyalgia
time. Fibromyalgia
negative
loops
feedback
can
so
loops will
generalizations
reason
discouragement,
both of which
are.
feedback
loops
progress,
they
can
environmental
opposite
can
often with
factors
can
also
so
trigger
symptoms, such
as
can
serve
the
lead to increased
pain and
poor
or
amplify secondary
of additional
Affective Disorder
negative
confusion
related to treatment
make decisions
lead
lies in the
and
even more
may
as symptoms
fibromyalgia
in turn
vary
can
elusive? One
function simultaneously,
Another
is
sufferers
difficult
lead
between symptoms
The relationship
feedback
can
that
downward
if left unrecognized
spiral and
patient.
fibromyalgia
inconsistent
or
syndrome
fibromyalgia
degenerative
and triggers
feedback
in which
same
negative
as
negative
symptoms, which
feedback
loops. Certain
sleep; however,
as
seasons
34
35
criteria associated
observed
phenomenon.
linked conditions
negative
more
with Fibromyalgia,
Significant
does provide
are not
by definition
are a
but rather
commonly
some
research evidence
feedback
It is important
diagnostic
can
as an
amplifier
in Fibromyalgia
but
Medical System
to effectively
diagnose
fibromyalgia.
As the diagnosis
the
presence
approaches
they
may
diagnosis
of fibromyalgia
if
may
a
altogether
of doctors lack
partially
are
as
practitioner
as a true
is in
diagnosis,
an
in-depth understanding
it
can serve to
alleviated. Improvement
supplemented
Another
such
by excluding
take different
particular
of fibromyalgia
options
syndrome
symptom.
A large percentage
frequently
only be achieved
bypass
individual
can
of fibromyalgia
and therefore
of fibromyalgia
leads to
a cure,
and
generic
is maximized
be
options.
however, and
as
chiropractic
individuals
providers
or massage
from
do not
therapy, and
even certain medications may not be covered by some insurance plans. Therefore,
if a particular treatment approach is not approved by a patients insurance
company it may never be discussed as an option for the patient. This can have huge
ramifications for patients who may actually receive benefit from those treatments.
A massive
drive treatment
restrictions
and required
approvals
care team.
35
36
Admittedly,
insurance
companies
face
an
manage
of trying to
the treatment
fibromyalgia
are
approaches
expanding
alternative
to
manage
their availability
treatments
patients
of patients, all
no
question that
they do.
for fibromyalgia;
proven treatment
approaches
for
companies
are
some
insurers
to included complementary
of covered services
and
such
of insurers. Furthermore,
recent economic
Without
therapies,
these offerings
scope
multi-disciplinary
range
a manner
when approving
are
in
model. Insurers
Effective
plans.
many
downturns
individuals
comprehensive
on
the
altogether.
care
health
in the
Insurance
are
an
in
untenable
multi-disciplinary
for
patients
any
of fibromyalgia
is typically
the most
single health
overall
fibromyalgia
medicine, chiropractic,
behavioral
massage
focused medicine
will want
take responsibility
on
can
medical specialties
that
a team
nightmare
individualistic
difficult
one
medicine,
that
can
that
to be
individual
fighting
symptoms
care
and the
extremely
in general
approach.
for
someone
overwhelmingly
an expert
possible
is
be
providers. Self-Management
As
many
It is not physically
approach provides
self-management
can
are not
one-size-fits-all
is
approach to
manage.
36
37
Consumers
that there is
phenomenon
as
unfortunate,
many
sense
cure
every
almost
come to expect
it gives
individuals
false
of security and
inaccurate
Pill to
Magic
is
an
understanding
of how medicine
truly
are
as advanced nor as
as most
believe them to
Americans
on
failure
it is
This is particularly
case
the
for fibromyalgia.
only treatments
fibromyalgia
of those treatments
are
or
depression
among
even more
condition in order to
no
known
one
for
many
a percentage of
particular
no
such
cure
expectations,
feeds
manage
move
cure
in only
to
The
- so surely
effective
result in
complicated
It is vitally important
or
doing it)
major hindrance
disease
can
effective,
understanding
therapy
For fibromyalgia
There is
only partially
with reality.
and make
a very
are a
complicated
effectively.
treatment. There is
no
magic
pill.
of fibromyalgia.
For
(FDA) recently
many
Americans
approved
who do
cursory
research
37
38
may
this FDA approval as meaning that the U.S. government has certified
as a cure and thus it is the magic pill they are seeking. Unfortunately,
case. Lyrica is not a cure for fibromyalgia, and for those patients in
this
upon
their doctors
guidance
interpret
Lyrica
is not the
may
There
Treatment
Effective
are many
extremely
Overwhelming
causes
suspected
symptoms
fibromyalgia
not
pill.
magic
Options
of fibromyalgia,
and they
vary
and evaluation
difficult
by about 40%.
from patient to
of overlapping
on
combination
care
provider is going to be
or
dietary supplements.
metabolizes
and
uses
various treatments.
effective
for
one
has
challenges.
Dietary factors
Certain drugs
may
may
Determining
particular
agree
approach is most
and research
have
an
may
alternative
to note,
no
many treatment
options and
single
impact
on
also play
the combination
patient involves
patients will
patient
an expert
multifaceted
Furthermore,
of pharmaceutical
is that
effective
among experts
long-term
of treatments
of
as
the
that is most
a process
of
trial-and-error.
38
39
As noted in the
diagram to the
left
- multiple
negative
loops
feedback
may
function
simultaneously
feeding
an
ongoing decline
in overall health
that drives
worsening
of
fibromyalgia
symptoms.
Patients should
utilize diagrams
like this to chart
and document
how
fibromyalgia
is
playing out in
their
own
bodies. Nothing
fancy is required
- crude
diagrams
can
same
a
hand-drawn
serve
purpose as
fancy computer
comprehensive
presented
in
generated
base of understanding
your
individual
the
thing is to build
is being
case.
39
40
4:
Chapter
are
Self-Management:
There
1.
unique. So is
are two
choices when it
Learn to effectively
comes to
manage
managing
fibromyalgia:
it yourself
OR
2. Option #2 is
see
years
option exists.
thinking
Taking Responsibility
for managing your own fibromyalgia. Taking
a decision; it is an action. It means taking control. The
move from a path of dependence, confusion, hopelessness,
responsibility
so
step in doing
and fear to
is to
path of knowledge,
you
you act upon
or concept in history, it
means accepting the
This
can
be
may
one
has
one
feel capable of
people,
is
can
many
the
observe, evaluate,
you are
YOU. No
and that
first
action.
do it! No
40
41
- Laying
Education
you
the Foundation
is the cornerstone
Education
Knowledge
is
primary
fibromyalgia
you,
your
for Success
of successful
you
need to
engage
in
options available
to
your care.
symptoms
learning efforts
treatment strategy.
As mentioned
magazines,
in chapter
newsletters
one
understanding
such
as
on
and Chronic
Furthermore,
information
care
providers, such
about fibromyalgia.
Make it
as a
up to
date
as
well
of Pain Management,
as
all
as
therapists,
nurses,
on your
pharmacists,
and
journey to understand
relationship.
you with a
your
can
provide
individual. Magazines
Pain Association,
Academy
have websites
related to fibromyalgia
and Chronic
and American
related to fibromyalgia
these organizations
can
you as an
the American
publish newsletters
number of journals,
and facilitate
fibromyalgia.
regularly
that
regarding fibromyalgia
Fibromyalgia
information
are a
and
engage
all
you
in dialogue.
fibromyalgia
proven
an
found
on
you
read
source
of information,
is
of low
best treatment
patient. If
indispensable
quality information
method! Fibromyalgia
testimony
manifests
itself differently
X worked for
no one
in each
one person,
be
41
42
that treatment
may not
work for
yourself
sure to
you
The
purpose
of
support
groups
fibromyalgia
you.
groups are
you to see
allow
are
how
who are
of the same trials and obstacles that you are, they can help you
your own fibromyalgia and allow you to evaluate different
treatments in context. Support groups also increase the pace of learning, as you are
able to share things with other group members.
disease.
support
Since fibromyalgia
comprised
of individuals
many
going through
to better understand
Your Fibromyalgia
Defining
Your fibromyalgia
is unique. It manifests
your
your
loops and
feedback
your
possible
response to treatments
you
than it does in
even your
triggers,
fibromyalgia
in
itself differently
causal factors, to
Before
condition
can
be effectively
causes,
possible
possible
will change
fibromyalgia
ongoing, however
You
are
over
your
your
life, including
condition
source
on a daily
of information
basis and
you
true inventory
of
your
about
your
it. Focus
on
inspecting
you
facilitates
up.
the
your
fibromyalgia.
You
closely how
find in
a manner
that
Baseline
In order to effectively
ground
of
will be
and self-awareness
Fibromyalgia
process
Laying Down
your symptoms,
the evaluation
live with
managed,
is present in
Note all of
evaluate
your
your
fibromyalgia,
it is important
42
43
detail
your
you are
fibromyalgia
now,
including what
some
you
or
basic charts
and
any
questions
diagrams
that
to be currently working in
material into
an
seem
organized
Building
Your Team
that
company to
you
will need
in
members
because of
foremost
lack of leadership
economic
more
capable than
scientist, Constitutional
expert, research
environmental
up
into
one.
as
being
a great
many
he is to be recognized
by history
recognize
where
your
strengths
comes to
lie. Acknowledge
But, if
in
managing
into
does not
self-management
to understand
important
managing
your
your
primary
an
into
skills, research
43
44
address
your
fibromyalgia,
and then
Take Action
Once
you
your
have defined
fibromyalgia,
who
you
Finally, selected
elements
of
sympathetic
your
you are
from
team. Remember,
up to you to determine
you need and who can
provide it to you.
One
way to
maximize
what
best
the
of the role
effectiveness
play
in
specific role.
For example, if
partner,
or a
genuinely
your spouse,
close friend is
good at listening
and providing
comforting
44
45
guidance, rely
on
that individual
for emotional
you
someone who is able to assist you with running errands, transportation for
you or your children, and housekeeping, solicit their help for those activities. For
times when you need to relax or find a distraction from your symptoms on a bad
day, have someone you can rely on to go out with you for coffee or lunch, or to a
movie or museum. Everyones needs are different, and you may find that you dont
need many people to assist you; other individuals may require even more
have
assistance
that
to distribute the
responsibilities
of different
people,
so
Setting Goals
It is important
fibromyalgia.
to targetable
put
you on
to focus
projects
As
Consider
you
efforts
detailed look at
are as
your
what goals
complicated
management
as
of
on
specific aspects of
fibromyalgia,
you set
any
is! Specific
complicated
goals, remember
your
in the successful
associated
self-management
paramount
your
goals
on
can
be
with actions.
the following
examples:
This is not a
a concrete outcome
specific goal. It is
vague
and does
to achieve it.
45
46
My Sleep."
to make it
more
room
actionable
for
and specific.
and "Reduce
my
morning stiffness.
can
be tied.
comes to
When it
establishing
leading to incremental
expectations
one
achievement
of instant gratification,
you can
success can
and
be achieved
even more
upon
The best
you
way to
a
address problems
systematic,
your
Once
you
have identified
is to
problem
multiple
causes,
therefore
approach to addressing
combination
them.
you
manner.
it is important
that
of solutions
fall
that arise in
defined
Recognize
and
Problem-Solver
attack them in
that
steps.
be
minutes,
Become
can
the
above
fight, and
is accept this
do for yourself
reality, plan for it, and expect it. Each if the goals mentioned
measured,
easy to have
this is a tough
of goals. Although it is
have identified
potential treatment
ready to try
As
effectiveness.
may
Recognize
be achieved
through
possible
solutions, be
combination
sure
solution to
and evaluate
your
their
some cases
one solution.
problem in
46
47
Evaluating
Treatment
Your symptoms
Options
your
and
can gauge
factors and
Eliminating
When
you
you
what
the severity of
evaluate
you are
may
my
particular
can
team! Review
members
who
potentially
what
are most
not let
a team
members
It is also important
you.
is
decisions. DO
industry
make
Treatment
who understands
better
is not
your
should be
your
specific
specific factor;
specific factor.
areas
where it
you are
evaluating
appropriate
one
your
the only
your treatment
dietary supplement
targeted
or
industry
you, or
and considering
your
opinion. Do
decision-making.
What
are
What
What
possible
the negative
negative
possibilities?
interactions
you
should Ibe
on
the
lookout for?
How likely
are
my
case
scenario?
life overall?
"What
are my
associated
with this
option?"
47
48
Case Studies
means.
with fibromyalgia
Fred is prescribed
care
physician
because
that is what the doctor has read should be effective, he has little actual
experience
or
muscular
disorientation.
and dizziness
is largely defined by
impairment
including
common
severe
truck driver,
Double Ooooops.
Fred
be in for
it to
his
fatigue, deep
and
are
drowsiness
doctor prescribed
may
severe
dizziness
things likely to be
symptoms. Fred is
or
cure
fibromyalgia.
heads out
some
on a
same
day his
problems!
OR
her fibromyalgia
therapist
pervasive
as a
sleep impairment
combination
or
approach
(though
she
caffeine
as a
her primary
and
potentially
medications
may test
any
problems
are
she experiences.
in Marys
her fibromyalgia,
manage
to test different
so
she
can
be
side effects of
aware
of what
evaluated
his treatment
are
in
progressing.
the odds
now
for
to increase her
kava, and passion flower. Mary has written down the possible
be causing
driving her
in the mornings
dietary supplements
may
care
massage
other prescription
energy,
group.
at length, consulted
favor
over
may
the long
options
have
run.
- Mary
has. Lyrica
may
in
abdicating
to
the
48
49
management
to
of his fibromyalgia
victim to magic
someone
pill syndrome.
Self-Empowerment
steps
empowerment.
and
prerequisite
are
but they
can
They enable
calculated
also
for developing
positive
and managing
an
feedback
are not
effective
an
only
and
necessity
treatment approach,
symptoms
less depression
Empowerment
Success Demonstrated
Empowerment
Or:
+ Education + Care
Responsibility
Team
Goals
+ Treatment
Evaluation
Empowerment.
When
by relying
to do it
your
goals. Without
empowerment
that
knowing
that
can
or
your
what
approach
systematic
and
reassurance
to do and how
through implementing
that not
every treatment
of causal emotions
reduces confusion
self-encouragement
fully understanding
undermine
every treatment
most initiatives will yield no
to understand
(in fact
It also provides
drives
important
over
results,
to know
time yields
which ultimately
drives
49
50
Self-Management
Successful
Conclusion
self-management
managing
your
important
systematic
approach is
systematic
upon a
the critically
treating fibromyalgia
without
must rely
companies,
well. Understanding
well-defined
self-management
as
plays in
that self-management
half-measure.
and supported
program.
(Chapter
6)
50
51
5:
Chapter
Treating Fibromyalgia:
you.
to
comprehensive,
discussion
It is important
to understand
you
need to know
with
options
options available;
you
What
about the
process
of elimination
options
Medical Specialists
to assemble
well-rounded
so many
Foundation
following
physicians
offer physician
are
additional
team of individuals
include
resources
Good
The
www.co-cure.org/Good-Doc.htm
website:
http://fmscommunity.org/findingadoctor.htm
www.sover.net/~devstar/provider.htm
FibroTrack
Care Provider
Database
potential members
to
your team,
to
ensure
for
you to screen
and
about
51
52
When
fibromyalgia.
examples
of
success
you meet
with
medical specialist,
etc.). Be
a new care
such
patient feedback,
to accept
you as an
in discussions
about
your
different
you
feedback
must be
relative to
a two way
your
opinions
their
your own
engage
doctors
Make
sure
evaluation
that
their general
their providing
therapies
as acupuncture,
provider team. Take the time and make the specific effort to
are
additional
and specialists
they
any
and chiropractic.
care
in relation to fibromyalgia
way
ask for
were,
of those treatments
sure to
sure to
observations
be
own
you
wish to
and
channel.
physician. This
When choosing
has experience
to
manage
with fibromyalgia
breakthrough
The following
wish to include
of strategies
pain.
is
Rheumatologist:
Rheumatologists
arthritis, autoimmune
individuals
internal medicine
physicians
and treatment
with fibromyalgia
of their diagnosis
are
may see a
rheumatologist
who
of arthritis
treat
Many
early in the
course
are
specially
pain
52
53
fibromyalgia
Psychiatrist:
are
on
pressure.
Psychologist:
are
Psychiatrists
well-trained
that
are
may
cognitive
can
Psychologists
trigger
be instrumental
or worsen
fibromyalgia
Neurologist:
their depression,
of
process
a
and
their
fibromyalgia
processes
patients
with
part
in the
often
of
inability
chiropractic
Chiropractic
care
pain,
team.
Chiropractors
treating musculoskeletal
some
ways to cope
vitally important
Chiropractor:
exams.
are
events that
are
body transmits
be
fibromyalgia
to
can
of diseases
on
techniques.
and by identifying
psychologists
neurologists
patients
fibromyalgia
care
care team.
are
Neurologists
rheumatologists,
diseases
patients
and treatment
diagnosis
in the
to prescribe medication,
modification
means,
can
symptoms.
behavioral
extremely
be useful to fibromyalgia
are
in the assessment,
education
their depressive
Psychologists
post-graduate
for medications
patients in managing
integral part of
an
often
treatment team.
Psychiatrists
prevention,
are
and
are
specially
trained practitioners
nervous system
pass
four
years
on
are not
of post-graduate
care as a treatment
for fibromyalgia
who focus
disorders. Chiropractors
care
the usefulness
symptoms
improves
of
is conflicting,
their symptoms.
53
54
Massage therapist:
who
use
therapeutic
are
Massage therapists
pressure
touch and
For fibromyalgia
depression
patients,
in order to relieve
relaxation
be
and anxiety.
therapist:
Occupational
licensed
applied to muscles
pain, rehabilitate
healthcare
are
therapists
Occupational
providers
specially trained,
who
are
experiencing
difficulty
on
peoples
therapists
modify
can
are
patients, who
physical limitations
an
individuals
be beneficial
way
therapists
can
the
can
to fit
environment
to fibromyalgia
in which they live
patients modify
fibromyalgia
obviously
with illness
frequently
associated
difficulties
result in improved
as a
help
symptom
control.
Dietitian:
principles
Registered
dieticians
are
healthcare professionals
are
national board
suffer from
irritable
who
are
are
healthcare
of movement
the bodys
widespread
patients how to
Naturopath:
overcome
Naturopathic
naturopathic
basic sciences
as
physicians
functioning
as a
doctors focus
well
as
on
by restoring
mobility,
patients
can
be helpful in teaching
years
as
professionals
disorders. They
they face.
comprehensive
as
physical therapist
physical challenges
Naturopathic
prevention of disease,
mobility
pass
patients who
cystitis.
licensed
and treatment
to
required
frequently
Physical therapists
are
fibromyalgia
Physical therapist:
They hold
human
to complete dietetic
also required
internships
who apply
nutrition-related
diagnosis
and treatment.
of post-graduate
are
educated
in all of the
54
55
education
emphasis
on
disease prevention
also required
to complete four
acupuncture,
homeopathic
years
may
person
of the whole
conventional
with
of wellness. They
board
exams.
therapies
in
an
and
Naturopathic
treatment team.
patients
on
and alternative
an
are
pass professional
of a fibromyalgia
be useful members
care
approaches,
therapeutic
addressing
both
are
on patient care in terms
a one-size-fits-all
viewed as a partnership
of
relationship
is
relationship
itself is unique
approach to treatment.
Create
When
you
Partnership
have found
or
your team,
with
underscore
Below
are a
schedules,
Physician
who meets
it is important
overloaded
your
physician
many
to develop
high patient-to-physician
you to
you
who
you
feel is
relationship
with him
be
as
prepared
accomplish
as you can at
resources
each appointment.
that:
55
56
1. Prepare
an
agenda before
your
accomplish
at that particular
explanation
of
paperwork
appointment.
appointment.
symptom?
Do
you
Know what
Do
you
need
need medication?
you want to
diagnosis or an
Do you need
2. Rehearse
a new
you
situation before
getting his
or
description
so
that
Review
and
with
3. Take
improved
my
from exercise.
4. Present to
initiatives
specifics
your
that
doctor
express
new treatment
of what
your
effectiveness,
you
have
from other
the value
treatment ideas.
you converse with your doctor, be sure to leave the appointment with
some concrete answers to key questions. Ask, "what is your diagnosis (i.e.,
whats wrong?); what is your prognosis (i.e., what is the outlook?); what
tests (if any) are needed; what treatments (both medical and behavioral) are
advisable, and when you should return for a follow-up visit?"
5. As
or
you
up your
understand
all that
your
exercise
you
understand
you, repeat
you
recommends you
you.
For example,
increments
each day,
time.
56
57
FDA-Approved
Pharmaceuticals
Three prescription
drugs have
now
been approved
Administration
associated
with fibromyalgia:
for
more
on
detailed information
our
Lyrica,
these medications;
website,
www.fibromyalgia-treatment.com
Lyrica
Lyrica (pregabalin)
treat neuropathic
is manufactured
as
epilepsy. The
understood,
means
however
pain. It
seen
improvements
as a
Lyrica is taken
450mg
per
headache,
dry mouth,
or
rare.
individuals
common side
nausea, vomiting,
arms
patients
per
day, usually at
gas,
constipation,
concentrating,
dose of 300 to
bloating, elevated
confusion, forgetfulness,
twitching, increased
mood,
anxiety, loss
reactions
women
who
certain medications
Individuals
on
nerves.
many
with fibromyalgia,
although
everyone
such
is not
swelling of the
speaking, difficulty
difficulty
can
it is believed
by the FDA to
Savella
Savella (milnacipran)
is manufactured
fibromyalgia,
improvements
Savella
by Forest Pharmaceuticals,
in fibromyalgia
may
help
some
individuals
inhibitors,
or
everyone
overall
with
achieve
in overall functions.
Inc. and is
it is in
as
known
class of medications
selective
in mood, particularly
understand
that that
your
mental health
in
may
younger
patients,
change in
are
unexpected
that
serotonin reuptake
an
so
can cause
it is important
unexpected
way
to
when
57
58
you
to communicate
doctor immediately,
aware
your
any
to
changes
group
your
members
once or
twice
minimize
Savella is
nausea,
however
day, preferably
need to be monitored
by
your
doctor
on a
with food to
Your blood
pressure
will
are
currently
taking medications
Cymbalta
Cymbalta
(duloxetine)
generalized
is FDA approved
nerve damage),
or muscle pain
and fibromyalgia
from conditions
pain. It
such
osteoarthritis.
Cymbalta
capsule. It is important
that
nausea,
may not
be felt for
vomiting, constipation,
up to
and
with diabetic
is taken
you
bone
is
an
once a
day
as a
of depression
(pain associated
as
can
long-acting
or
chew the
so
changes
in sexual desire
or
weakness
Furthermore,
other medications
your
doctor
take. Also
Cymbalta
58
59
Antidepressants
is
Antidepressants
to treat depression,
known
as
neurotransmitters.
on
There
are
used
the bodys
These chemicals
both emotions
production
transmit
nerve
of chemicals
Tricyclic antidepressants
treat depressive
not used
typically
as a
cause a
used to
(TCAs):
neurotransmitters
considerable
and serotonin.
Although
are
of
common
TCAs
include Anafranil, Elavil, and Tofranil. Common side effects include dry
mouth, vision disturbances,
constipation,
increased
sleepiness,
increased
sexual problems.
Monoamine
antidepressants,
they
are most
considerable
MAOIs
are
examples
nausea
in
many
As
as
as a
well
racing heartbeat,
neurotransmitter
interactions.
can
prevent dangerous
depression
(SSRIs):
These
are a newer
the available
class of
amount of the
more common
examples
of SSRIs include Prozac, Zoloft, Paxil, Lexapro, and Celexa. Many patients
sex
drive
or
inability
will experience
sexual problems
headache,
nausea,
are
(such
as
low
reversible.
insomnia, and
feeling.
59
60
SNRIs increase
the availability
feeling lightheaded,
headache,
Prescription
such
as
or
falling
sleep medications
that if
can
symptom of insomnia
There
as
sleep medications
may
(ramelteon),
you
for individuals
who have
insomnia). However, it is
be much
commonly
Eurodin (estazolam),
that
In such instances,
be of benefit.
you
Sonata (zaleplon),
prescribed
to help
Lunesta (eszopiclone),
you stay
you
fall
Halcion (triazolam),
are
Drugs that
as
generally
available
therefore
are
underlying
ultimately
prescription
an
fibromyalgia
manage,
are
to understand
important
blurred vision,
nausea.
Sleep Medications
A number of prescription
difficulty
a newer
changes
Also
of serotonin and
Rozerem
Restoril (temazepam),
Ambien CR
Anti-Anxiety
The most
Medications
common
benzodiazepines.
situations
that
are
or
in
class of anti-anxiety
While antidepressants
medications
are
generally
over a
as
long period of
can
more quickly and therefore are ideal for short-term use in specific
response to symptomatic episodes. Examples of benzodiazepines
time to continuously
begin working
be habit forming,
commonly
Ativan
60
61
(lorazepam),
common
side effects of
benzodiazepines
grogginess,
The most
confusion,
and nightmares.
Pain Management
Analgesic
There
management
overview
any
are a
in fibromyalgia
of selected
analgesic
available
is
for pain
brief
examples:
The most
Narcotics:
relieving medication
a
as
is
nerve
on
pain by working
pain receptors
found
on
the
cells themselves.
Common examples
narcotics
of
include Tylenol
OxyContin,
use
example, Tylenol)
can
be
very
can
habit-forming,
Anticonvulsants:
seizure disorders
have analgesic
Neurontin
Topamax
as
properties
(gabapentin),
(topiramate).
anticonvulsants
are
medications
drowsiness,
as
Trileptal (oxcarbazepine),
Scientists
Lyrica (pregabalin),
and
how these
common
(for
urinating.
Anticonvulsants
such
may
medications
dizziness, drowsiness,
of appetite, abdominal
or
include headache,
nausea,
vomiting, loss
61
62
Muscle relaxants:
are
Muscle relaxants
medications
Flexeril (cyclobenzaprine),
(metaxalone),
for
use
or
of depression
drowsiness,
women,
older adults,
drug/alcohol
used only
on a
short-term
many
as
depression.
such
caused by arthritis,
nerve
group,
(imipramine),
Norpramin
history
way
shingles, migraine,
in which
is not
group
of antidepressants
which includes
(desipramine).
or
drugs such
Anafranil (clomipramine),
these medications
constipation,
with
antidepressants
fibromyalgia
and it generally
the tricyclic
dependence,
antidepressants
Skelaxin
recommended
fibromyalgia,
are not
basis.
Antidepressants
understood,
They
those individuals
Anti-depressants:
pain conditions,
or
dizziness, possible
Valium (diazepam),
by pregnant
as
Pamelor
associated
is
Tofranil
(nortriptyline),
purpose
Amitriptyline,
and
with the
use
of
dry mouth,
in blood
pressure.
Over-the-counter
options:
pain medications,
such
Aleve (naproxen),
fibromyalgia,
headache
but
as
Common over-the-counter
Tylenol (acetaminophen),
can
are not
(non-prescription)
Advil (ibuprofen),
specifically
designed
to treat
symptoms, such as
naproxen, and aspirin can cause stomach
of aspirin) can interfere with blood
62
63
for Pain
Coping Strategies
pain associated
so
will
your
to have
It is important
your
with fibromyalgia.
As
your
belt to help
pain changes
from
to be flexible and
options to help
and
most appropriate
Distractions
that divert
your
attention
away
from
important
a
a hobby you
you can do
without aggravating your symptoms), or taking a slow,
easy walk in a nice park. In addition, relaxation techniques can also be of
coping mechanisms.
Examples
a
so
enjoy (if
of distracting
tremendous
help. Deep-breathing
meditation,
yoga,
exercises,
can
and visualization
everyone,
willing to explore
your
mainstays
Dietary
therefore
activities
progressive
muscle relaxation,
all be beneficial.
management,
it is important
every
not
for coping.
Supplements
symptoms
associated
with fibromyalgia.
Some have
effective
important
for
medications
dietary
commonly
investigated
an
overview
and associated
of
It is by
treatment.com.
63
64
5HTP:
5-HTP (5-
hydroxytryptophan;
L-5
hydroxytryptophan)
is
chemical naturally
as a
of the amino
acid L-tryptophan.
can
It
also be produced
synthetically
from the
as
Griffonia
5-HTP
simplicifolia.
works by increasing
serotonin. 5HTP is
to treat
variety
fibromyalgia,
the bodys
production
widely available
of symptoms
of
chemical known
dietary supplement
and conditions
as
depression
with
and anxiety,
muscle tenderness
Ribose:
Ribose is
supplement
improve
nausea,
kind of
sugar
athletic performance,
recovery,
energy stores. It has
muscle function
also been used to help prevent muscle cramping, pain, and stiffness
patients with various disorders
some
of the musculoskeletal
as a treatment
to support its use for
research available
demonstrated
to corroborate
however
these findings.
Acetyl-L-carnitine:
Acetyl-L-carnitine
there is little
such
in
system. Although
for fibromyalgia,
as
energy.
is
naturally-occurring
It has historically
Alzheimers
disease,
amino acid
memory
loss, depression,
64
65
available
information
symptoms
associated
regarding
generally
taking
can
It
odor. Acetyl-L-carnitine
fishy
as
to treat the
of acetyl-L-carnitine
however
(fibro
are
use
with fibromyalgia,
cognitive dysfunction
benefit. Side effects
the
may
it
be of
cause
nausea,
Coumadin
or
(warfarin)
Sintrom
(acenocoumarol).
Magnesium
over
is required
for
maintaining
also supports
use
of oral magnesium
supplements,
SAMe:
as
cramping,
SAMe,
or
chemical reactions
the neurotransmitters
fibromyalgia
may
occur
use
dopamine
increased
synthetic form of
worse.
may
compound
many
the availability
of
be of benefit for
Individuals
who have
sugar,
can result in
common
nausea, skin
urination, headache,
hyperactivity,
coenzyme
side
thirst,
(GHB), ascorbigen,
treatments
is
improvements
and
effects associated
pain and
include diarrhea
kidney failure.
as
anxiety should
it
well
that
as
S-adenosylmethionine,
it,
supplements,
effective
tenderness.
abdominal
as an
as
possible
fibromyalgia
65
66
Diet
there is
Unfortunately,
and fibromyalgia.
in,
your
mean
your
in managing
Dietary modifications
improve
you
or
improvements
symptoms.
fibromyalgia
may
be able to
good thing!
attention to how
Some evidence
vegan
may
diets
help improve
the symptoms
associated
and decreased
with fibromyalgia,
larger and
Celiac Disease is
damaged,
and they
were
limited by small
numbers of subjects
association,
including
more
specifically
designed
preventing
it from absorbing
nutrients
at
any
products. The
fibromyalgia,
makes
cause
the symptoms
an accurate
diagnosis
of celiac disease
can vary
between individuals,
pain, bloating,
symptoms
changes
irregularities,
arise
which
include
in appetite,
over
and
time
are
related
66
67
may
symptoms, fibromyalgia
overlapping
versa. In
at the same
commonly
addition, individuals
celiac disease
changes
that
or
are
may
be misdiagnosed
may
with fibromyalgia
can
generally
as
celiac
also have
be diagnosed
by
characteristic
of the condition.
Exercise
Research supports
the positive
impact of exercise
obese. Furthermore,
and reliable
effective
more
are primary causal
are overweight or
increases, so does the
has
fibromyalgia,
symptoms
of patients
symptoms.
things to understand
however, is that
inactive lifestyle
over 65%
that as weight
no matter
as an
other treatment
of fibromyalgia;
severity of fibromyalgia
an
no
led
In fact,
your
care must
entire life
be taken. Regardless
or
or
just recently
reintroduced
and
of whether
you have
your
strive
Examples
may not
of exercises
include Tai-Chi,
yoga,
provide
modalities
water-based
regarding
proven
very
effectiveness
these exercise
patients
important. Although it
can
to
be difficult
regimens
can
be found
on our
website,
www.fibromyalgia-treatment.com.
67
68
Therapies
A number of additional
many
therapeutic
commonly
and alternative
Below is
are also
some of
treatments
brief overview
of
Balneotherapy:
Balneotherapy
including increasing
body temperature
It is thought to improve
improve
metabolism,
use
is the therapeutic
disease. Balneotherapy
of water to heal
germs
blood circulation
improve endocrine
and
means,
number of
oxygen
and viruses).
delivery
to cells,
used by
the most
used therapies:
Chiropractic:
Chiropractic
musculoskeletal
these disorders
and
have
focuses
nervous systems
on overall health
care
Chiropractic
on
is frequently
immune
relaxation.
examination,
drug-free,
can
as
headaches.
Massage therapy:
pressure
applied to muscles
use
of touch and
injuries,
uses
connective
release therapy is
Myofascial
therapist
as
sustained
which the
in the fascia,
or
Aromatherapy:
Aromatherapy
involves the
use
as therapy to improve physical health and wellare scented liquids that are removed from plants by
or pressure. They contain the chemicals that naturally give the
essence, or fragrance. Aromatherapy is administered in different
ways,
including
inhalation
various
lotions/creams
providing
inhalation
is believed
organs
to have psychological
or massage, are
psychological
or
sedate
either through
benefits.
believed
Cognitive behavioral
therapy is
and psychological
a type
of talk
as
as a
well
symptoms. It is based
68
69
on
Reflexology:
the application
that ultimately
Reflexology
is
pressure to
of
can
and feelings
behavior
an
alternative therapeutic
treatment of fibromyalgia
provide
can
can
comprehensive
be found
also learn
Alternative
alternative
and alternative
therapies
therapies
scope
barely
available
scrape
for the
of this eBook to
Medicine, at www.nccam.nih.gov.
69
70
6:
Chapter
across
Experts
reputable
associations
you are
track what
fibromyalgia.
that: provide
maximize
you
have
your
with regard to
experience
gone
you
fibromyalgia
authors to
your
purpose
you
processes
required
to
we
none
Approach
the potential of
you expect,
so.
what
you
A Systematic
to devoted researchers
Unfortunately,
do
example
need treatment,
a course
done is collected
analyzed
(i.e.,
relevant
a treatment.
you questions
of action, i.e.,
itself in
Essentially,
about
your
to
you as a
body to
your
doctor has
treatment)
your
what
a course
of action
you
leave their office and return two weeks later, having tried the treatment and found
it unsuccessful,
action recommendation.
By using
process
70
71
You
are not a
your
fibromyalgia
doctor, however
with
you
defined, systematic
collection
achievable
and
anyone can
can
do it. You
of
you;
it is easily
you expect.
one:
Collect
Track EVERYTHING associated with your fibromyalgia.
This is a crucial first step. Think of it as the data collection process that allows
you to take inventory of and record your signs and symptoms. Record how you
feel each day, the symptoms you experience, possible triggers for those symptoms,
what treatments you are trying, and how those treatments are impacting your life.
Also note relevant factors such as sleep, stress, work pressures, family issues,
anxiety and physical or emotional happenings. You are looking to build a record of
how fibromyalgia is impacting and being impacted by your life.
Step
Step two:
symptoms,
Analyze
- EVERYTHING
your treatments,
you track.
on your
their effects
Analyze
body,
and recorded
it,
support
out before
Step three:
Utilize
its patterns,
nuances,
evaluation
can you
Using
and effects
based
truly
to remember
and analyzing
scenario
is unrealistic
on your system of data collection, analysis, and evaluation as you try new
on your findings. As those actions give you benefit or not you
must continue to assess your symptoms by tracking and analyzing them to
determine if more modifications are needed. Remember, this is an ongoing
process. But you can do it! INSPECT what you EXPECT!
to rely
actions based
71
72
72
73
73
74
74
75
Tools
Recording
you expect.
your system
or
notebooks
the old-fashioned
symptoms
logged in
diary of
free-written
The information
record
on a
one notebook,
your personal
or tape
attempted
thoughts
may
your
treatments
journals, forms,
recorder
may
or
voice
work for
data. You
may
some
have
be augmented
recorder, however
system
paper-based
and compartmentalizes
in these notebooks
voice
way, with
a tape
and/or video,
with voice
those recordings
are
memos you
away
you may
may make the
filed
or
misfile
for
you
journal
or paper,
in the evaluation
of
losing valuable
your
data that
fibromyalgia.
75
76
How do
you
you
across a
bunch of journals
and binders?
How do
organized
scattered
Admittedly,
a more
using
traditional
paper-based
you
managing
tough adversary
Yes,
and
few preliminary
can
you are
if
reading this,
and folders
on your computer
storing all of
your
fibromyalgia
as
group.
fibromyalgia-related
your
team,
you
are a
started
on your
path
dedicated to
Do not mix
your
and support
you
specifically
information.
Obtain copies of
you
self-management
Create directories
such
are,
Odds
tips that
toward successful
scan
copies
right to
see
and
Create
care
template
provider
have prior to
provider
you
your
Use spreadsheets
tools
use
for recording
visit, to
These
using FibroTrack,
to
in the loop
Spreadsheets.
and
document
as
it
are
in which
case
reduced in value by
tool
the complete
to track EVERYTHING.
you can
or
you
your
and to keep
have (unless
your
record. Spreadsheets
journal
is easily
abilities.
76
77
your computer skills are limited and you are uncertain how to create a
template or a spreadsheet
learn! Ask a family member or friend to help
you, or utilize many of the free training videos that are available online.
Resources such as Open Office are great for this and are free.
If
Tracking
There
Symptoms
are many
handwritten
to
use a
methods
that
journal, however
spreadsheet
system). Regardless
of which
to always do.
As
you
evaluate
symptoms. All
as
means
your
fibromyalgia,
or even
being insignificant
identifying
unrelated. As
using.
important to track everything in a consistent, systemized manner.
your symptoms on a scale from 1to 10, with 10 being the worse. If you
use a spreadsheet, create some type of chart that you can note every day. If
you choose to use a spreadsheet, get into detail and make your symptoms specific.
Group your symptoms together by type, using such categories as muscular pain,
tender points, mind/body functioning, internal pain, and so on.
It is extremely
Rate all of
cannot
Tracking
you observe, do so
your symptoms. Track your sleep;
you slept, what time you went to
bed, what time you woke up, and how many times you arose during the night. Rate
the quality of your sleep was it restful? Did you have nightmares? How did you
feel upon waking up? Use the same granular detail when tracking and recording
other causal relationships, events, and triggers, such as fatigue, stress, emotions,
As
you
Causal Relationships,
using the
same type
relationships,
associated
as
how long
pain, and
conditions.
77
78
you
accidents
actions
or
your
you
undergo,
any
any
abnormal
experience.
can be
can
relationships
you
activities
evaluated
you structure
specific
treatment options.
***Understanding
events
are
information
process
individuals
symptoms
and causational
triggers and
your
managing
into relevant
of intelligent
Tracking
your
how
impacting
to effectively
ongoing treatment
data that
can
is critical
core
of enabling
Your Treatments
you track your treatments and everything relative to them, divide them into
groups to enable successful management. Examples of these groups might be
drugs, dietary supplements, alternative remedies, therapy programs, exercise, diet,
and so on. Keep records relative to all of these, and note any questions that you
have. Integrate your team, and keep track of questions, answers, and opinions. All
of this information is valuable for integrating data into a bigger picture strategy.
As
to track what
you
took it, and how much. For exercise, record how long
at which
you
78
79
Intelligent
Determining
A Concept
and
your
purpose of
treatment(s)
for
System
fibromyalgia
decisions
on
collected
and analyzed
data.
your
you to
intelligent
evaluate
error system,
trial and
specific task
treatments
as
fibromyalgia
using
you
your
will conduct
as
well, make it
and support
group
into the
process.
you are
on your
implement
spreadsheet
you
visualize
the impact
emerge during your data review and analysis will help to identify these,
may not have been visible to you before you began analyzing and reviewing
your fibromyalgia in a focused manner. By identifying these negative feedback
loops and applying strategies to stop them, you can likely make a noticeable
impact on certain variables associated with your fibromyalgia. Through data
that will
which
you can
identifying
identify specifically
the
causal relationships
areas
where
you
and triggering
need to TARGET
your
treatment focus!
79
80
a reverse
of the
you undertake exercise as a treatment, you may find that you begin
you lose weight, it may improve your depression. Improvements
your depression may result in further reductions in anxiety and stress, all of
which may culminate in improved pain, fatigue and other symptoms.
For example, if
to lose weight. As
in
Exercise
/ Stress reduced
symptoms.
on one
action. Decide
your
factor when it
here to effectively
gain control
small piece of
your
writing down
can
be
as
simple
as
a start
grabbing
- and
Integrate
your
efforts into
management
your
initiative
at
manage
notebook
and
getting started is
your
you need to
step at a time, one
do and how, then assign time to it and get it done. One small
new treatment
is to simply take
typically
fibromyalgia
principals
time
- what
of Intelligent
to work!
Understand
than
that this
successes.
process
will be frustrating
successes
more
failures
the
your symptoms possible, gains will most likely come in small steps. One treatment
initiative may yield a 20% reduction in a symptom. Another later effort may yield
another 15% improvement. Some efforts may make things worse (stop those!).
Over time you will build a treatment regimen that you can document is reducing
your symptoms by a meaningful amount. Even though some symptoms may never
be totally eliminated, the ability to reduce their impact on your life by 50% or more
can be the deciding factor between a full and happy life where your managing your
fibromyalgia and a life of misery where fibro is dictating to you.
80
81
Chapter
Effective
7:
systems
The Future:
are
the key to
an
"FibroTrack"
effective
management
process.
Systems
are
action.
compartmentalize
and fragment
systems
are
rudimentary
your
is 90% pointless
(the remaining
can
allow
10% is empowerment)
you to
effectively
unless
evaluate
you
and convert
81
82
FibroTrack:
FibroTrack
Internet
an
is
been specifically
your
designed
Self-Management
user
cloud
interface
up to
facilitate
based
fibromyalgia.
FibroTrack
of
Enhanced
intuitive, graphical
a mouse
provides
users
with
into
an
overall fibromyalgia
specific
system:
videos
resources
Educational
- all accessible
user
into the
help functions.
Treatment
of pharmaceuticals,
- the Internets
dietary supplements,
mobile device.
symptoms
or
or are
impacted
by
your
fibromyalgia.
of treatment
information.
Comprehensive
tools including
user
defined
Online support
users to
and communications
tools.
groups
capabilities
that link
82
83
Social networking
Complete
user
over
control
groups
and
easy
tracking of
efforts.
ensure
privacy. Users control what data is shared and what is kept totally private.
Discussion forums
Webinars
- ongoing
server
Secure
However, technology
approaches
has fortunately
previously
easy
achieve
data collection
analysis
accessible
through intuitive
capabilities
as
in the palm of
recently
huge
as
several
for security.
years ago.
impossible.
Now,
we are
able to
research, achieve
by sophisticated
technology
and
accessible
possible
capabilities
moved in directions
thought to be ridiculously
intelligent
never
your
dreamed
of
are now
hand!
While
we
were not
like FibroTrack
Capabilities
on a
variety of fibromyalgia
certainly
implementing
required. The
We invite
will find
you to
visit
our
website, www.fibromyalgia-treatment.com,
management
variety of fibromyalgia-related
associated
out
our
Remember,
our
knowledge
our
fibromyalgia
articles
where
you
self-
on a
wide
methods, and
can
In addition to
topics, including
conditions, diagnostic
sharing
you
tool (FibroTrack),
83
84
fibromyalgia;
it offers
comprehensive
you.
as
streamlined
as
us
help
you
by making
possible.
our
website,
the information
Also note
- 10%
fibromyalgia
awareness
from FibroTrack
go
toward funding
-----------------------------------------------------------------
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85
Disclaimer
The information
contained
a doctor,
or accountant. Any
lawyer
advice, information,
opinion expressed
his
own
more than
you for
personal experience
purposes
entertainment
perspectives,
and provided to
purposes only.
any sort,
or medical
opinion based on
of
ideas
the authors
and
informational
only.
in this ebook
understanding
that said
Please understand
may
that there
or
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and opinions
services
or
responsibility
The publication
any
are some
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may
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85