FMS Community Newsletter #33
Wednesday, December 11, 2002

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FMS Community Newsletter #33
Wednesday, December 11, 2002
1967 members and 12 new members. Welcome!
Featured link: Surviving the holidays

This week's article at the CFIDS/Fibromyalgia Self-Help program
( is "Surviving the Holidays." Read tips for
reducing stress and increasing enjoyment of the holiday period, offered
by guest author Karen Lee Richards, Vice President of the Natonal
Fibromyalgia Association. The article is the latest in our Coping
Strategies series.

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This week's news:
1) ABCs of Fibro
2) How to survive holiday toxicity
3) The effects of exercise and education, individually or combined, in
women with fibromyalgia.
4) When You Feel You Can't Go On
5) The contribution of pain, reported sleep quality, and depressive
symptoms to fatigue in fibromyalgia.
6) Coffee Consumption May Improve Cognitive Function in Older Women
7) Participate in pain education initiative
8) Fibromyalgia is common in a postpoliomyelitis clinic.
9) Treatment of Fibromyalgia: Managing a Multifactorial Syndrome
1) ABCs of Fibro

ACCEPTANCE - of consequences and boundaries of your new reality.
BALANCE - in all areas of your life.
CHANGE - ancient wisdom holds that the only thing that's certain is
DENIAL - the first stage of reaction to any sudden, unexpected,
unpleasant event.
EXERCISE - do what you can...with what you have... and where you are.
FATIGUE - rest your mind as well as your body.
GENTLE - with your movements.
HUMOR - smiles, laughter, and a sense of humor... help in the healing
IMAGERY - great way to escape pain and fatigue for a brief time.
JOURNAL - a written record of symptoms ... weather ... emotions ...
helps identify patterns.
KNOWLEDGE - learn all you can about Fibromyalgia.
LIFE style changes - ongoing process
MANAGEMENT of medications
NEGATIVE thinking
PACE - conserve energy ... set priorities
QUIET place to relax.
RELAXATION exercises.
SLEEP - develop good sleeping habits.
TESTS - a fact of FMS living.
USE - the largest muscle for the task.
VOICE - your needs.
WELLNESS - attitude and lifestyle.
XANADU - "an idyllic, beautiful place" ... imagine yourself in one for
YARE - means "to be ready or prepared"... don't let a flare creep up on
ZEAL -"enthusiastic and diligent devotion in pursuit of a cause, ideal,
or goal"

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2) How to survive holiday toxicity

by Kandee Biren
eDiets Relationships Specialist

Many people go through life feeling “alone” and feeling that no one
understands or cares about what may happen to them. Even in a room full
of people -- a loving partner, children, family and friends -- many
people feel as if they are all alone. It is a feeling that comes from
within and permeates everything one does in life.
These feelings are even more pronounced during the holiday season. That
is why it is more important than ever to reach out and establish strong
holiday support systems. For some, the idea of a holiday support system
or a strong support system may be a new and different concept. Any
group, person or situation that enables you to express yourself without
fear, judgment, and criticism, and provides a safe atmosphere with
confidentiality can play a valuable role when it comes to your holiday
support system.

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3) The effects of exercise and education, individually or combined, in
women with fibromyalgia.

J Rheumatol 2002 Dec;29(12):2620-7

King SJ, Wessel J, Bhambhani Y, Sholter D, Maksymowych W.

Health Science Council Office, University of Alberta, Edmonton, Alberta,

PMID: 12465163

OBJECTIVE: To examine the effectiveness of a supervised aerobic exercise
program, a self-management education program, and the combination of
exercise and education for women with fibromyalgia (FM).

METHODS: One hundred fifty-two women were randomized into one of 4
exercise-only, education-only, exercise and education, or control. The
duration of the study was 12 weeks. All subjects were analyzed at 3
before study, immediately upon completion, and 3 months after completion
the intervention program on measures of disability, self-efficacy,
tender point count, and tender point tenderness. Of the 152 women,
data were available for 95 and 69 who complied with the protocol. In
to determine the group time interaction, a 2 way analysis of variance
repeated measures was used for each measure.

RESULTS: The only significant group time interaction was reported with
compliance analysis for the Self-Efficacy Coping with Other Symptoms
subscale and the Six Minute Walk. If the program was followed, the
combination of a supervised exercise program and group education
persons with FM with a better sense of control over their symptoms.
improved in the 2 groups undergoing supervised aerobic exercise
However, the improvement in fitness was maintained at followup in the
exercise-only group and not the combined group.

Conclusion: Subjects receiving the combination of exercise and education
and who complied with the treatment protocol improved their perceived
ability to cope with other symptoms. In addition, a supervised exercise
program increased walking distance at post-test, an increase that was
maintained at followup in the exercise-only group. Results demonstrate
challenges with conducting exercise and education studies in persons
with FM.
4) When You Feel You Can't Go On

I'm sorry that you're hurting so desperately right now. I know how
painful the seconds, and minutes, and days can be, how long the nights
are. I understand how very hard hanging on is, and how much courage it

I ask though that you hold onto one day at a time. Just one day, and
slowly this despair will pass. The feelings you fear you're trapped in
will serve their purpose, and then fade away. Difficult to imagine isn't
it? Almost impossible to believe when every cell in your body it seems
cries out in agony, desperately in need of comfort. When it feels like
the only thing in the whole world that can touch your pain and banish it
is beyond your grasp. And after all this time, the assurance that you
will heal has become an empty, broken promise.

Just let one tiny cell in your body continue to believe in the promise
of healing. Just one. You can surrender every other cell to your
despair. Just that one little cell of faith that you can heal and be
whole again is enough to keep you going, is enough to lead you through
the darkness. Although it can't banish your suffering, it can sustain
you until the time comes for you to let your pain go. And the letting go
can only occur in it's own time, as much as we would like to push the
pain away forever.

Hold on. Hold on to appreciate the beauty of the earth, to feel the
songs of the birds in your heart, to learn and to teach, to laugh a
genuine laugh, to dance on the beach, to rest peacefully, to experience
contentment, to want to be no other place but in the here and now, to
trust in yourself, and to trust your life.

Hold on because it's worth the terrible waiting. Hold on because you are
worthy. Hold on because the wisdom that will follow you out of this
darkness will be a tremendous gift. Hold on because you have so much
love and joy waiting to be experienced. Hold on because life is
precious, even though it can bring terrible losses. Hold on because
there is so much that you can't now imagine waiting ahead on your
journey - a destiny that only you can fulfill. Hold on although your
exhausted and your grasp is shaky, and you want more than anything to
let go sometimes, hold on even though. Please hold on.

So much in life can be difficult, even impossible to understand. I know,
I know ... So many of us have cried in despair, why? why? why? and still
the answers and the comfort failed to show. Survival can be a long and
lonely road, in spite of all those who've stumbled down the path before
you. And it can be a treacherous, torturous journey - so easy to get
lost, and yet impossible to avoid even one painful step.

And the light, the light at the end of the dark tunnel for so long
cannot be seen, although eventually you'll begin to feel its' warmth as
you move forward. And forward you must move in order to get through the
hell of remembering, of despair, of rage, of grief. Keep looking forward
please. Rest if you must, doubt your ability to survive the journey if
you have to, but never let go of the guide ropes, although when you
close your fingers around them, your hands feel empty, they are there.
Please trust me, they are there.

When you're exhausted, when all you have to count on is a weakened,
weary faith, hold on. When you think you want to die, hold on until you
recognize that it's not death you seek, but for the pain to go away.
Hold on, because this darkness will surely fade away. Hold on. Please
hold on.

Tammie Byram Fowles, LISW, Ph.D

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5) The contribution of pain, reported sleep quality, and depressive
symptoms to fatigue in fibromyalgia.

Pain 2002 Dec;100(3):271-9

Nicassio PM, Moxham EG, Schuman CE, Gevirtz RN.

California School of Professional Psychology, San Diego, 10455 Pomerado
Road, 92131, San Diego, CA, USA

PMID: 12467998

The major objective of this research was to evaluate the predictors of
fatigue in patients with fibromyalgia (FM), using cross-sectional and
assessment methodologies.

In the cross-sectional phase of the research involving a sample of 105
patients, greater depression and lower sleep quality were concurrently
associated with higher fatigue. While pain was correlated with fatigue,
did not independently contribute to fatigue in the regression equation.
a subset of patients from the cross-sectional sample (n=63) who
participated in a week of prospective daily assessment of their pain,
quality, and fatigue, multiple regression analysis of aggregated
daily scores revealed that previous day's pain and sleep quality
next day's fatigue. Depression from the cross-sectional phase was not
related to aggregated daily fatigue scores.

A path analytic framework was tested with disaggregated (removing
subjects variability) data in which pain was predicted to contribute to
lower sleep quality which, in turn, was predicted to lead to greater
fatigue. The results revealed that poor sleep quality fully accounted
the positive relationship between pain and fatigue, thus substantiating
mediational role of sleep quality.

The findings are indicative of a dysfunctional, cyclical pattern of
heightened pain and non-restful sleep underlying the experience of
in FM.
6) Coffee Consumption May Improve Cognitive Function in Older Women

NEW YORK (Reuters Health) Nov 01 - Elderly women who consume relatively
large amounts of coffee appear to outperform less frequent coffee
drinkers in certain tests of cognitive function, according to new study
findings. In contrast, this association was not observed among elderly

"It is biologically plausible that caffeine lessens age-related
cognitive decline," Dr. Marilyn Johnson-Kozlow and her colleagues write
in the November 1st issue of the American Journal of Epidemiology.

The researchers, from the University of California, San Diego in La
Jolla studied 890 women and 638 men who completed a variety of cognitive
tests. The average age of the participants was 72.6 years.

During the study, the participants were surveyed regarding how many cups
of coffee they drink on an average day, and the number of years they had
been coffee-drinkers. Regular coffee drinkers were defined as those who
drank at least one cup of coffee each month. The highest category of
coffee use was approximately 5 cups each day.

The researchers found that women who drank relatively large amounts of
coffee over their lifetimes outperformed their peers in tests where they
had to recall a list of words and reproduce a geometric form after a
delay of 30 minutes. High lifetime female coffee drinkers also did
better on tests where they counted backward from 100 in multiples of
seven, and spelled the word "world" backwards.

The link between coffee consumption and mental abilities persisted even
after accounting for potential confounders, such as age, education, and
use of estrogen replacement therapy.

However, coffee drinking was not linked to all of the tests designed to
measure participants' mental acuity, the authors note, suggesting that
caffeine may have a "differential effect," improving mental functioning
in some areas, but not others.

There may have been too few men in the study to detect a benefit from
coffee consumption for this group, the researchers postulate.
Alternatively, it is possible that some silent factor may be either
clouding the relationship in men, or creating a false relationship in

Still, men and women may simply respond differently to caffeine, the
authors conclude.

Am J Epidemiol 2002;156:842-850.
7) Participate in pain education initiative

What are the common barriers to effective pain management and how can I
avoid them?

What is the difference between addiction, physical dependence, tolerance
and pseudo-addiction of opioids?

When choosing an opioid analgesic for chronic pain, what type is most
commonly used? Are around-the-clock dosing schedules preferred over prn
administration? How do I manage breakthrough pain?

These are just a few of the many questions that the National Pain
Education Council (NPEC) initiative examines on behalf of physicians,
nurses, and pharmacists.

As co-chairs of this innovative educational endeavor, we invite you to
make use of the many tools, services, and CME/CE programs that the
National Pain Education Council (NPEC) has to offer. Practitioners
interested in advancing their knowledge in the management of pain will
find assessment tools they can download and use in their daily practice,
gain free access to recent abstracts from key articles on pain
management from the national library of medicine, and multi-media,
interactive CME/CE programs that include case-based learning systems. We
trust that you will find your participation challenging and ultimately,
rewarding. Please visit our site below and join us in advancing the body
of knowledge in pain management - with the ultimate goal of relieving
patients' suffering and improving their health and quality of life.

Richard Payne, MD
Pain and Palliative Care Service
Memorial Sloan-Kettering Cancer Center
New York, New York

Russell K. Portenoy, MD
Department of Pain and Palliative Care
Beth Israel Medical Center
New York, New York

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8) Fibromyalgia is common in a postpoliomyelitis clinic.

Trojan DA, Cashman NR.

Department of Neurology, Montreal Neurological Institute and Hospital,
McGill University, Quebec.
Arch Neurol 1995 Jun;52(6):620-4

OBJECTIVE: To determine prospectively the occurrence and clinical
characteristics of fibromyalgia in patients serially presenting to a
postpolio clinic. Fibromyalgia may mimic some of the symptoms of
postpoliomyelitis syndrome, a disorder characterized by new weakness,
fatigue, and pain decades after paralytic poliomyelitis.
DESIGN: Case series.
SETTING: A university-affiliated hospital clinic.
PATIENTS: One hundred five patients were evaluated with a standardized
history and physical examination during an 18-month period. Ten patients
were excluded because of the absence of past paralytic poliomyelitis.
INTERVENTIONS: Patients with fibromyalgia were treated with low-dose,
nighttime amitriptyline hydrochloride or other conservative measures.
MAIN OUTCOME MEASURES: Patients with fibromyalgia had diffuse pain and
11 or more of 18 specific tender points on examination (American College
of Rheumatology criteria, 1990). Patients with borderline fibromyalgia
had muscle pain and five to 10 tender points on physical examination.
RESULTS: Ten (10.5%) of 95 postpolio patients met the criteria for
fibromyalgia, and another 10 patients had borderline fibromyalgia. All
patients with fibromyalgia complained of new weakness, fatigue, and
pain. Patients with fibromyalgia were more likely than patients without
fibromyalgia to be female (80% vs 40%, P < .04) and to complain of
generalized fatigue (100% vs 71%, P = .057), but were not
distinguishable in terms of age at presentation to clinic, age at polio,
length of time since polio, physical activity, weakness at polio, motor
strength scores on examination, and the presence of new weakness, muscle
fatigue, or joint pain. Approximately 50% of patients in both the
fibromyalgia and borderline fibromyalgia groups responded to low-dose,
nighttime amitriptyline therapy.
CONCLUSIONS: (1) Fibromyalgia occurs frequently in a postpolio clinic.
(2) Fibromyalgia can mimic some symptoms of postpoliomyelitis syndrome.
(3) Fibromyalgia in postpolio patients can respond to specific
9) Treatment of Fibromyalgia: Managing a Multifactorial Syndrome

10-02-2002 By Sherron M. Stonecypher

Fibromyalgia syndrome (FMS) is a chronic pain disorder that causes
widespread pain, tenderness, and stiffness in muscles, as well as
Although there is currently no cure for fibromyalgia syndrome (FMS),
management of its symptoms is possible. The management process begins
with a
thorough examination and diagnosis by a physician trained in tender
recognition. Once fibromyalgia and any accompanying conditions are
diagnosed, the healthcare provider and patient can decide on the best
approach for treatment.

Fibromyalgia is a multifactorial syndrome, making it challenging to
The most common goals in the management of FMS are to:

* break the pain cycle,

* restore sleep patterns, and

* increase functional activity levels (1).

Currently, no single intervention has led to long-term relief for the
majority of people with FMS (2). Therefore, fibromyalgia is best managed
using a multidimensional treatment approach. "Common treatments include
lifestyle modifications to help conserve energy and minimize pain,
anti-depressant or tricyclic drugs to help regulate sleep patterns, pain
medications to control severe pain, a gentle exercise program, massage
similar physical therapies, dietary and environmental changes to keep
immune system in good shape, and relaxation therapy." (3) Using a
multidimensional approach requires proactive involvement from health
professionals, family members, and the patient, working together as a


Medications are prescribed to FMS patients for primarily two reasons:
reducing pain and improving restorative sleep. Medications that act as
stimulants or disrupt sleep, as side effects, should be prescribed with
caution. Blood test should be done on a regular basis to check for side
effects of medications. As another precaution, medications should be
for use by women in their childbearing years since this comprises a
percentage of the fibromyalgia population.

Fibromyalgia patients may take an average of three of the following
medications: a nonsteroidal analgesic, an antidepressant, a muscle
benzodiazepine, and sometimes a narcotic analgesic (4). Tricyclic
antidepressants are one of the most prevalent medications used by FMS
patients because they "appear to lessen stage IV sleep disturbance and
thought to increase levels of brain serotonin and other
(5) In addition to antidepressant drug therapy, "patients are instructed
sleep preparation and sleep habits to assist in maintaining restorative
sleep patterns." (6)

New drug therapies continue to be evaluated on a regular basis. Based on
recent studies, some researchers think growth hormone replacement
may be a promising treatment (7). Studies have also indicated that the
of medication, which blocks substance P receptors in the brain, may
fibromyalgia symptoms (8). But currently, no drug therapy alone has
complete relief from fibromyalgia symptoms (9).


One of the most effective interventions for long term management of FMS
physical exercise. It has been shown that exercise increases time spent
deep sleep (10). This perhaps explains why aerobic exercise has
value in the treatment of FMS (11).

Based upon evaluation of tender points, pain, range of motion, and
physical therapists and physicians can prescribe an exercise program.
key to initiating an appropriate exercise program should be an
individualized regimen that respects the FMS patient's limitations but
not bow to them." (12) A program should consist of low-repetition
strengthening; passive stretching; postural exercises; and low-impact
aerobic exercise (cycling, swimming, walking) (13). To avoid
fibromyalgia symptoms, patients should never exceed existing pain limits
when exercising and stretching (14).

Bennett and McCain advocate that people diagnosed with fibromyalgia
these exercise guidelines:

* exercise three times a week,

* at a pulse rate of 85% of the target heart rate for age (for most
120-150 beats per minute),

* for a duration of 40 minutes 15.

"Patients who are deconditioned should start out with just 3-5 minutes
exercise every day and gradually increase as tolerated." (16) Once a
regiment is established, symptoms may amplify if the exercise routine is
interrupted (17). This is a reminder that compliance is important.
compliance can perhaps improve with greater supervision, encouragement
a team approach and by making exercise a lifelong habit (18).

Patients should experiment with a variety of exercise activities to find
what best suits them. Walking, bicycling, and various types of home
equipment are popular. Aerobic water exercise in heated water is often
recommended for patients with injuries, who are overweight, or are
to weight-bearing activities (19). Water exercise is particularly useful
when patients are initially starting an exercise program (20). As
increases, other forms of exercise can be implemented into the routine.

"Exercise is most effective if done in the late afternoon or early
perhaps because of its known effect on deep sleep." (21) One study found
inconclusive evidence of the beneficial effects of aerobic walking on
symptoms of fibromyalgia (22). But other researchers have found that
"regular physical exercise, rather than drugs or specific physical
approaches, correlated highly with low symptomatic FMS activity scores."


There are many therapeutic treatment options for FMS patients. These
include physical therapy. "Physical therapy has provided many FMS
relief from symptoms, objectively increased strength and endurance
them the subsequent ability to lead more productive and active

To assist in stress management, patients and their family members may
it useful to participate in support groups, educational workshops, and
psychological or psychiatric counseling. Meditation, spiritual aids,
relaxation tapes, hypnosis, yoga, tai chi, and biofeedback are other
therapeutic techniques fibromyalgia patients may find useful for stress
reduction (25).

Fibromyalgia patients often pursue a variety of complimentary medical
treatments. According to one study, chiropractors were consulted with
highest frequency, but FMS patients had the most satisfaction from
therapy when a less rigorous massage technique was used (26).
Acupuncture is
another effective therapy. "Acupuncture, and especially
when using traditional acupuncture sites for needle insertion as opposed
tender-point sites, has been shown to raise pain threshold levels by 70%
patients with FMS." (27) Although many patients benefit from
medicine, patients should be cautioned not to substitute these
for traditional medical treatment without consulting a physician (28).


Nutrition specialists can recommend appropriate nutritional supplements
as "calcium and magnesium (1,000-1,500 mg per day, to be taken at
B-Complex, or a good multi-vitamin" (29). Nutrition specialists can also
educate patients about foods which have an effect on FMS symptoms. For
instance, several patients experience improvement in their symptoms when
they follow a low-fat diet (30). Foods that increase the body's level of
serotonin (a neurotransmitter that may help induce sleep) may also be
beneficial. Sugar and carbohydrates both enhance the production of
serotonin; however, carbohydrates (when not consumed with a protein)
increase serotonin for a longer duration (31). Use of caffeine,
and alcohol should be limited because these substances interfere with
patterns and energy levels (32).


In any chronic pain condition, education is an essential component that
helps patients and their families develop appropriate expectations,
understand limitations, and make informed treatment decisions. Education
also teach patients how to help themselves. Several "authors have
that patients should be educated in the FMS disease process and coping
strategies, including stress recognition and management, sleep patterns,
nutrition, energy conservation, pain management and cognitive-behavioral
intervention programs, medication, and physical conditioning" (33).

Physical therapists can advise patients how to use heat (moist hot
heating pads, whirlpools, and warm showers or baths) to decrease muscle
spasm, increase blood flow and diminish tension (34). "Physical
can also instruct patients in the proper use of cold modalities (ice
ice massage, and cool baths) to anesthetize localized areas of pain
points) and break the pain cycle." (35)

Education in energy-conservation techniques includes learning
time-management skills. Fibromyalgia patients must learn not to
overdo. Proper body mechanics, postural exercises, and the use of
devices can also reduce muscular energy requirements (36). When
demanding tasks need to be completed, it is best if the tasks are
over several days rather than in one block of time (37). Overexertion
trigger symptoms, and require bed rest for several days to recover.
who learn time-management skills and stop when they have reached their
physical limits will lead more productive, balanced lifestyles (38).


1. S Krsnich-Shriwise, "Fibromyalgia Syndrome: An Overview," Physical
Therapy 77, January (1997): 72.

2. Krsnich-Shriwise, "Fibromyalgia Syndrome."
DA Nye, "Fibromyalgia: A Physician's Guide," 4 November 1998, (4 May

3. FibroNorth, "FM Basics," 1998, (5 May 1999), Treatment.

4. Krsnich-Shriwise, "Fibromyalgia Syndrome."

5. DL Goldenberg, "Controversies in Fibromyalgia and Myofascial Pain
Syndrome," In Evaluation and Treatment of Chronic Pain, Edited by GM
(Baltimore, Maryland: Williams & Wilkins, 1992), 172.

6. Krsnich-Shriwise, "Fibromyalgia Syndrome," 73.

7. RM Bennett, "The Growth Hormone Connection," Paper presented at
1996 National Convention on Fibromyalgia: A New Era of Understanding;
Convention Center, Portland, Oregon; 6-8 September, 1996. E Bagge, BA
Bengtsson, L Carlsson, J Carlsson, "Low Growth Hormone Secretion in
with Fibromyalgia: A Preliminary Report on 10 Patients and 10 Controls,"
Journal of Rheumatology 25, January (1998).

8. RM Bennett, "A New Era of Understanding," Paper presented at the
1996 National Convention on Fibromyalgia: A New Era of Understanding;
Convention Center, Portland, Oregon; 6-8 September 1996.

9. Krsnich-Shriwise, "Fibromyalgia Syndrome."

10. JA Hobson, "Sleep After Exercise," Science 162, no. 861 (1968).

11. GA McCain, DA Bell, FM Mai, PD Halliday, "A Controlled Study of the
Effects of a Supervised Cardiovascular Fitness Training Program on the
Manifestations of Primary Fibromyalgia," Arthritis and Rheumatism 31,
September (1988).

12. C Sherman, "Managing Fibromyalgia with Exercise," The Physician and
Sportsmedicine 20, no. 10 (1992): 169.

13. Sherman, "Managing Fibromyalgia."
Krsnich-Shriwise, "Fibromyalgia Syndrome."

14. Krsnich-Shriwise, "Fibromyalgia Syndrome."

15. RM Bennett, G McCain, "Coping Successfully with Fibromyalgia,"
Care (1995).

16. Nye, "Fibromyalgia," paragraph 20.

17. Nye, "Fibromyalgia."

18. Bennett and McCain, "Coping Successfully."

19. Krsnich-Shriwise, "Fibromyalgia Syndrome." Nye, "Fibromyalgia."

20. Nye, "Fibromyalgia."

21. Nye, "Fibromyalgia," paragraph 22.

22. DS Nichols, TM Glenn, "Effect of Aerobic Exercise on Pain
Affect, and Level of Disability in Individuals with Fibromyalgia,"
Therapy 74, April (1994).

23. G Granges, P Zilko, GO Littlejohn, "Fibromyalgia Syndrome:
Assessment of
the Severity of the Condition 2 Years After Diagnosis," Journal of
Rheumatology 21, (1994): 523.

24. KB McCoy, "Fibromyalgia," Paper presented at the Oregon 1996
Convention on Fibromyalgia: A New Era of Understanding; Oregon
Center, Portland, Oregon; 6-8 September 1996.

25. J Kelly, R Devonshire, J Fransen, Taking Charge of Fibromyalgia: A
Self-Management Program for Your Fibromyalgia, (Minneapolis, Minnesota:
Abbott-Northwestern Hospital, Arthritis Care Program, 1993). Bennett and
McCain, "Coping Successfully."

26. M Pioro-Boisset, JM Esdaile, M Fitacharles, "Alternative Medicine
Use in
Fibromyalgia Syndrome," Arthritis Care and Research 9, no. 1 (1996).

27. C Deluze, L Bosia, A Zirbs, A Chantraine, TL Vischer,
"Electroacupuncture in Fibromyalgia: Results of a Controlled Trial," BMJ
305, no. 6864 (1992): 1250.

28. Nye, "Fibromyalgia."

29. Kelly et al., Taking Charge of Fibromyalgia, 48. (Return to text)
30. Nye, "Fibromyalgia."

31. Kelly et al., Taking Charge of Fibromyalgia.

32. Kelly et al., Taking Charge of Fibromyalgia.

33. Krsnich-Shriwise, "Fibromyalgia Syndrome," 72.

34. KM Nies, "Treatment of the Fibromyalgia Syndrome," The Journal of
Musculoskeletal Pain 44, (1992).

35. Krsnich-Shriwise, "Fibromyalgia Syndrome," 74.

36. Krsnich-Shriwise, "Fibromyalgia Syndrome."

37. Nye, "Fibromyalgia."

38. Kelly et al., Taking Charge of Fibromyalgia.

(c) Sherron M. Stonecypher. All rights reserved.
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