FIBROMYALGIA (FM) TREATMENTS

Since there is no cure for Fibromyalgia (FM), treatments are geared towards improving the quality of sleep and reducing pain. Treatments take on several different forms. There are medications, trigger-point injections, physical therapy, occupational therapy, acupuncture, acupressure, relaxation techniques, biofeedback techniques and osteopathic manipulative medicine.

Deep level sleep (stage 4 sleep) is crucial for many body functions such as tissue repair, antibody production, and the regulation of various neurotransmitters, hormones, and immune system chemicals. Therefore, sleep disorders that occur in FM are treated first because they may be a strong contributing factor to the symptoms of FM. There are many different types of treatments for sleep disorders to be considered.

Information contained in the FM/CFS/ME RESOURCES web site is intended as an educational aid only. Information is not intended as medical advice or for individual conditions or treatment and is NOT a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. ALL health information should ALWAYS be carefully reviewed with your healthcare provider.

Types of Treatments For FM (Alphabetical Order)

• Acupuncture
• Acupressure
• Biofeedback Techniques
• Chiropractic Care
• Craniosacral Therapy
• Experimental Protocols
• Homeopathic Remedies
• Hyperbaric Oxygen Therapy
• Intravenous Micro Nutrient Therapy
• Lifestyle Alterations

• Massage Therapy
• Medications
• Topical Medications
• Occupational Therapy
• Osteopathic Manipulative Medicine
• Physical Therapy
• Relaxation Techniques
• TENS Unit
• Trigger Point Injections
• Vitamins, Supplements & More

Acupuncture

Acupuncture is a technique of inserting and manipulating filiform needles into "acupuncture points" on the body. According to acupuncture teachings, this will restore health and well-being, and is particularly good at treating pain.

Acupuncture is thought to have originated in China and is most commonly associated with Traditional Chinese medicine. Different types of acupuncture (Japanese, Korean, and classical Chinese acupuncture) are practiced and taught throughout the world.

In a Mayo Clinic study, acupuncture significantly improved symptoms of FM. Among 50 participants, those who received acupuncture reported improvement in fatigue and anxiety, among other symptoms. Acupuncture was well tolerated, with minimal side effects.

Mayo's acupuncture study is one of only three randomized and controlled studies involving people with FM. Of the other studies, results were mixed. One study found acupuncture to be helpful, while the other reported that acupuncture was ineffective for pain relief.

Acupressure

Acupressure is a traditional Chinese medicine (TCM) technique based on the same ideas as acupuncture. Acupressure involves placing physical pressure by hand, elbow, or with the aid of various devices on different acupuncture points on the surface of the body.

Traditional Chinese Medicine does not usually operate within a scientific paradigm but some practitioners make efforts to bring practices into an evidence-based medicine framework. There is no scientific consensus over whether or not evidence supports the efficacy of acupressure beyond a placebo.

Traditional Chinese medicine's acupuncture theory predates use of the scientific method, and has received various criticisms based on scientific thinking. There is no known anatomical or histological basis for the existence of acupuncture points or meridians.

Acupuncturists tend to perceive TCM concepts in functional rather than structural terms, i.e. as being useful in guiding evaluation and care of patients. Neuroimaging research suggests that certain acupuncture points have distinct effects that are not otherwise predictable anatomically.

Biofeedback Techniques

Biofeedback is a form of complementary and alternative medicine which involves measuring a subject's bodily processes such as blood pressure, heart rate, skin temperature, galvanic skin response (sweating), and muscle tension and conveying such information to him or her in real-time in order to raise his or her awareness and conscious control of the related physiological activities.

By providing access to physiological information about which the user is generally unaware, biofeedback allows users to gain control over physical processes previously considered automatic. Interest in biofeedback has waxed and waned since its inception in the 1960s; at the beginning of the 21st century it is undergoing something of a renaissance, which some ascribe to the general upswing of interest in complementary and alternative medicine modalities.

A relaxation training program uses biofeedback-assisted relaxation training, autogenesis, progressive muscle relaxation, imagery, breathing exercises, distraction, and self-hypnosis techniques to help patients to reduce the overall level of stress in their lives. Relaxation techniques have also been effective in decreasing pain levels.

Craniosacral Therapy

Craniosacral Therapy, (also called CST, cranial osteopathy) is a method of complementary and alternative medicine used by massage therapists, naturopaths, chiropractors, osteopaths, occupational therapists, physical therapists, nurses, dentists, and doctors who manually apply a subtle movement of the spinal and cranial bones in an attempt to bring the central nervous system into harmony. This therapy involves assessing and addressing the movement of the cerebrospinal fluid (CSF), which can be restricted by trauma to the body, such as through falls, accidents, and general nervous tension. By gently working with the spine, the skull and its cranial sutures, diaphragms, and fascia, the restrictions of nerve passages are said to be eased, the movement of CSF through the spinal cord can be optimized, and misaligned bones can be restored to their proper position. This therapy is said to be particularly useful for mental stress, neck and back pain, migraines, TMJ Syndrome, and for chronic pain conditions such as Fibromyalgia.

A typical craniosacral therapy session is performed with the client fully-clothed, in a supine position, and usually lasts about one hour. A ten-step protocol serves as a general guideline, which includes:

• analyzing the base (existing) cranial rhythm
• creating a still point in that rhythm at the base of the skull
• rocking the sacrum
• lengthening the spine in the lumbar-sacral region
• addressing the pelvic, respiratory and thoracic diaphragms
• releasing the hyoid bone in the throat
• addressing each one of the cranial bones

The practitioner may use discretion in using which steps are suitable for each client, and may or may not follow them in sequential order, with time restraints and the extent of trauma being factors.

The therapist places their hands lightly on the patient's body, tuning in to the patient by "listening" with their hands. Therapeutic contact between the patient and therapist may involve entrainment between patient and practitioner. Patients often experience a sense of deep relaxation during and after the treatment session, and may feel light-headed. This is popularly associated with increases in endorphins, but research shows the effects may actually be brought about by the endocannabinoid system.

Craniosacral Therapy is claimed to be particularly beneficial in children. Adverse side effects of treatment are uncommon: in a study of craniosacral manipulation in patients with traumatic brain syndrome the level of adverse effects from treatment was 5%.

Craniosacral Therapy is not protected by statute either in the US or the UK, and there is currently no legal requirement to be trained to any standard or registered with a professional association. In the UK the Health Professions Council is consulting on whether to integrate all craniosacral therapists in the UK under their umbrella of state regulated professions.

Experimental Protocols

It's hard to research treatments for fibromyalgia (FM) and chronic fatigue syndrome (CFS/ME) without coming across protocol using experimental treatments and theories. These articles will help you explore the claims made by supporters of these protocols as well as the science both behind them and used to refute them. This information is not intended to either support or debunk the experimental treatment protocols, but is here to help you find out the facts on both sides so you can make informed decisions about treating your FM or CFS/ME.

The Glutathione Protocol
The Glutathione Protocol, developed by Richard Van Konynenburg, PhD, focuses on restoring a process in your body that he says is blocked in people with chronic fatigue syndrome (CFS/ME) . At its root are findings that, according to Van Konynenburg, the majority of people with CFS/ME are deficient in glutathione. Before you can raise your glutathione levels, however, he says you need to unblock what's called the "methylation cycle," which is what's behind the low glutathione levels.

This treatment protocol is experimental, and there's little or no scientific evidence to support it. Many people with CFS/ME say it's been extremely helpful to them, but these are strictly personal opinions that do not imply scientific fact.

If you've never heard of glutathione, you're not alone. It's not well known by the public, and even doctors have only begun to understand its importance. Glutathione is an antioxidant and antiviral tripeptide that also helps clean heavy-metal toxins out of your body. According to glutathione researcher Jimmy Gutman, MD, it's involved in dozens of critical cellular processes that protect us from toxins in the environment.

Your body can become low in glutathione over time because of constant demands combined with a low level of its components in the typical modern diet. It also declines as we age, and some researchers believe maintaining higher levels would fight many age-related illnesses.

Dr. Van Konynenburg has outlined two forms of the Glutathione Protocol -- a simple approach and a customized one.

Note: This information is intended to familiarize you with this treatment protocol so you can decide whether to look into it further. These are not complete instructions. The simplified protocol includes several daily oral supplements intended to break the methylation cycle. They are:

• Folapro
• B12/folate
• A specific complete vitamin & ultra-antioxidant
• Phosphatidyl Serine Complex
• Perque B12
• SAMe (S-adenosylmehtionine)
• Methylation Support Nutriswitch Formula

After you start the treatment, your symptoms might get worse for awhile. If so, Dr. Van Konynenburg says you need to find out whether that's because your body is starting to kill viruses and detoxifying, or because you have a certain genetic abnormality that causes an increase in an enzyme called cystathionine beta synthase (CBS).

To see which group you fall into, you'll need to have your urine tested for toxic metals and amino acids, which may require you to go through a specialty lab (and that can be very expensive.) If the test reveals toxic metals, you're detoxing and can continue with the Simplified Approach. If the amino acids test shows elevated taurine and ammonia, you have the CBS problem and will need to switch to the Customized Approach.

The customized approach is a complex, 17-part protocol that requires some medical tests and will mean you'll need a doctor who's willing to help you with it. You may also end up paying for a lot of specialized tests.

The Guaifenesin Protocol
It's hard to look online for fibromyalgia treatments without coming across references to guaifenesin. The Guaifenesin (gwy-FEN-e-sin) Protocol for treating fibromyalgia (FM) was developed by Paul St. Amand, MD, an endocrinologist who has FM, as do several members of his family. At its root is the theory (as yet unproven) that our cells aren't able to make enough energy because of low levels of adenosine triphosphate (ATP), and that energy deprivation leads to the many symptoms of FM. He says the bodies of people with FM accumulate too much of the mineral phosphate, which supports your body's metabolism and performs many vital functions. This, he says, leads to underproduction of ATP. St. Amand believes the drug guaifenesin makes your kidneys pull excess phosphates from your cells, thereby reversing the process he says causes fibromyalgia.

Guaifenesin is on the market in several forms and is primarily an expectorant used to thin mucus. It's in popular over-the-counter (OTC) medications such as Robitussin and Mucinex. It's also used as a muscle relaxant during anesthesia. St. Amand recommends against using most decongestants to get guaifenesin, however, and advocates either Mucinex or pure forms of the drug that can be obtained through certain websites. Because guaifenesin is not a prescription medication, it won't be covered by your insurance.

This protocol is experimental and neither the treatment nor the theory behind it is supported by scientific evidence. To date, only one double-blind, placebo-controlled study has examined it, and researchers found the Guaifenesin Protocol no more effective than a placebo. St. Amand says he's seen great success in his patients and a relatively small group people with FM swears by the protocol. Still, many leading FM experts are unconvinced that this is an effective treatment option.

The information here is not intended to either prove or disprove the Guaifenesin Protocol but is here to help you educate youself. At the end of this article, you'll find several links to help you learn more, including some that argue against St. Amand's theories and treatment methods.

On the upside, according to St. Amand, the only side effect of guaifenesin is mild nausea, that doesn't last long and only happens rarely. He says it is safe and effective even for children and doesn't have any known drug interactions.

On the downside is that, for the treatment to be effective, St. Amand says you have to avoid all sources of salicylates, which he claims keep guaifenesin from having the desired effect on your kidneys. Salicylates are known to have multiple effects on your body. In painkillers such as aspirin, salicylates block pain, break fevers and reduce inflammation. However, they also make your stomach more acidic, block the formation of protective mucous and increase bleeding. In most people, the liver and kidneys detoxify salicylates, but doctors generally avoid medications containing salicylates in people with kidney disease.

Salicylates are in all kinds of products, including:

• Anything flavored with mint, mint oil, menthol
• Oils, extracts or gels with plant names (except soy, wheat, corn, oats)
• Many herbal medications
• Many drugs, including aspirin and topical pain creams
• Many cosmetics and body-care products

Avoiding all salicylates is difficult and means you'll need to spend a lot of time researching the products you use. On his website, St. Amand makes suggestions for how to avoid salicylates and provides a link to a support group that will help you find appropriate products.

Also, during early phases of the treatment, you'll have cycling flare-ups that St. Amand says are proof that the treatment is beginning to work. Symptoms will likely be more intense that what you're used to for awhile, but he says over time the flare-ups will get shorter and less severe until you go into complete remission and no longer have any symptoms at all. The longer you've had FM, the longer he says it will take you to get to remission.

St. Amand disregards the standard tender-point test for diagnosing FM and says he's found a better way to identify the condition and to document physiological improvements. It's called "mapping."

In mapping, practitioners touch you with their finger pads as if they're trying to iron out underlying tissues. They find and document swollen spots in your muscles and connective tissues and note their size and how hard they are. That forms a basis for comparison after you've started the treatment. St. Amand says the most important part of your body for confirming a diagnosis is the left thigh, which he says is affected in 100% of adults with FM.

The Pall Protocol
Some researchers speculate that chronic fatigue syndrome (CFS/ME) and fibromyalgia (FM) could have a common cause. One researcher says that cause is nitric oxide, and that it is also responsible for multiple chemical sensitivity (MCS) and post-traumatic stress disorder (PTSD).

Dr. Martin Pall is a professor of microbiology at Washington State University and started looking into CFS/ME after he was diagnosed with it. The essence of his theory is that short-term stressors cause a build up of naturally occurring nitric oxide, which starts a vicious cycle and leads to long-term illness.

It's important to remember that this protocol is experimental and has not been scientifically proven. One study, however, does support the theory of dysfunctional oxidative pathways, and some people who've tried the protocol say it has worked for them.

The information here is not intended to either support or refute Pall's theory but is here to inform you about available theories and treatment protocols so you can make good decisions. It's important to include your doctor in your treatment decisions and to be monitored for any changes to your health.

Nitric oxide (NO) is all over your body and plays important roles such as transporting oxygen to your tissues and transmitting nerve impulses. Until the late 1990s, however, it was considered a toxin, and Pall considers it a toxin in his theory. Multiple studies show changes to the central nervous systems of people with FM and CFS/ME, and Pall says those changes would require high levels of NO.

Pall says high NO levels in the central nervous system in turn lead to elevated levels of peroxynitrite, which causes tissue damage. How do you get too much NO in your body? Pall lays out 12 possible stressors, 8 that lead to a direct increase, 4 that lead to an indirect one. The direct stressors are:

• Viral infection: CFS/ME, FM
• Bacterial infection: CFS/ME, FM
• Physical trauma: CFS/ME, FM, PTDS
• Carbon monoxide exposure: CFS/ME
• organophosphorus pesticide exposure: CFS/ME, MCS
• Toxoplasmosis infection: CFS/ME
• Volatile organic solvent exposure: MCS
• Autoimmune diseases: secondary FM

Studies have show the other 4 stressors trigger a response that leads to increased NMDA receptor activity, which is known to increase levels of NO and peroxynitrite (ONOO-). (NMDA receptors send signals in the brain and may be involved in cell damage.) These stressors are:

• Severe psychological stress: FM, PTSD
• Ciguatoxin exposure (from seafood): CFS/ME
• Organochlorine pesticides: MCS
• Pyrethroid pesticides: MCS

Note: NO levels also increase as a result of certain positive things, such as when you exercise, eat a low-fat diet, improve your nutrition or quit smoking, all of which experts consider to benefit people with FM and CFS/ME. Many researchers consider high NO levels to be good for your health.

Pall proposes that once a stressor causes a build up of NO, it puts in motion a vicious cycle that consists of several self-perpetuating loops. From there, it gets extremely technical and difficult to understand unless you're really knowledgeable about biochemistry. If you are, Pall has a complete diagram on his website. For the rest of us, here's an example of how just one 5-step loop works:

1. High NO level increases peroxynitrite level
2. Peroxynitrite increase causes oxidative stress (a build up of molecules that damage cells. Studies link oxidative stress to CFS/ME.)
3. Oxidative stress stimulates NF-kB (which controls expression of genes involved in immunity and cellular function)
4. NF-kB increases production of the enzyme iNOS (inducible nitric oxide synthase)
5. iNOS increases NO level, and we're back to step one

Pall has named the vicious cycle the NO/ONOO- cycle (pronounced "no, oh no!"). He says it happens at a cellular level, which is why one tissue can be in pain while the ones around it are fine. It also explains why symptoms can vary so vastly from one person to another.

Pall says elements of the NO/ONOO- cycle can explain a host of symptoms shared by CFS, FM, MCS and PTSD. (He offers them as plausible causes, not established ones.) These symptoms include:

• Learning and memory dysfunction
• Fatigue and sleep disturbance
• Chronic excessive pain
• Depression and anxiety/panic attack
• Immune dysfunction
• Irritable bowel syndrome
• Food allergies
• Orthostatic intolerance/hypotension (drop in blood pressure when standing that makes you dizzy)

To break the cycle, Pall says it needs to be "down regulated," which essentially means slowing it down by eliminating things that trigger it. For example, if stress makes you feel worse, it needs to be reduced or managed. Beyond that, he believes the complexity of the cycle requires multiple types of treatment.

Pall's paper on the NO/ONOO- cycle outlines a multitude of things - many of them nutritional supplements - that he predicts will down regulate the cycle. (Remember that this theory is unproven and these agents untested for treating this group of illnesses.) He also lists the treatment regimens used by five doctors who've found success treating one or more of these conditions and says the treatments all are likely to down regulate the cycle. As with all treatment options, you should talk to your doctor about what is right for you.

Pall's not the only one pointing to nitric oxide as a possible cause of these illnesses. Several researchers examining NO's role particularly in fibromyalgia are calling for studies into whether antioxidants are an effective treatment.

You May Also Like

• About FM
• Associated Conditions
• Causes
• Diagnosis
• Diet For FM
• Duration

• Facts & Tips
• FM vs CFS/ME
• FIQ
• FIQR
• Frequency
• History

• Mortality
• Myths
• Onset
• Pain Scale
• Pain Types
• Pregnancy
• Prognosis

• Pathophysiology
• Research
• Severity
• Subtypes
• Symptoms
• Tender Points
• Treatments

Homeopathy is a system of alternative medicine that aims to treat "like with like." Despite being widely discredited in scientific circles homeopathy has grown in popularity in recent years. Homeopathic remedies are used to balance the stress factors that underlie the symptoms of Fibromyalgia (FM). The symptom profile is matched to a homeopathic remedy that helps those symptoms. This is often a very effective, quick way of creating less of pain.

As always, tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Here is a list of favorite homeopathic remedies for FM symptoms:

Arnica
Arnica is an herb that can be used topically as a cream on specific areas of bruising and pain. As a homeopathic remedy, Arnica can be taken internally, in pellet form, to work more deeply on the trauma that is held in the muscles. Arnica works by improving circulation and reducing both emotional and physical trauma in the muscles. It is especially useful when an accident or other traumatic event may have caused the onset of FM.

Rhus Toxicodendron
This is used for stiffness that gets better once the client gets moving and when weather has an effect on the degree of pain. Rhus toxicodendron is often used to relieve pain in the joints, and works well on healing ligament strains. The Rhus toxicodendron client feels very restless and wants the stiffness and reaction to cold damp weather to improve quickly.

Bryonia
Bryonia is the homeopathic remedy that has symptoms opposite the Rhus toxicodendron remedy. Here, the client tries to stay as still as possible, since even the slightest motion makes the pain worse. These people tend to be very irritable and grumpy, not wanting to be touched, even though pressure on the point of pain often helps. Bryonia is indicated when there is hardness of muscle groups and headaches are common. Another indication for this remedy is when warmth makes the pain worse and cool applications feel better.

Causticum
Causticum is another homeopathic remedy for soreness, weakness and stiffness in the muscles that is worse from cold and/or overuse. Pain is also worse when the weather is dry and tends to be better in rainy weather. The muscles in the legs feel contracted, tight and sore, with restlessness at night. The forearms are weak, even though they are also stiff. These clients feel better in a warm bed or warm shower.

Gelsemium
Gelsemium is a remedy for FM when the limbs feel heavy, dull and lethargic. Headaches occur in the back of the head and neck, and there may be dizziness. This remedy is indicated when there is a low-grade fever with much aching, similar to having the flu all of the time. Gelsemium is also designated when symptoms are worse in damp, cold, or warm and wet weather, or after exertion.

Cimicifuga
Cimicifuga is a homeopathic remedy to use when there are spasms in the large muscle groups, the body feels sore and bruised all over, and there may be jerking and twitching of the muscles. The spine feels sensitive, and there is pain especially in the back, neck and shoulders. The FM clients that would benefit from Cimicifuga feel better with warmth and pressure, and feel worse with touch, motion, cold applications and during their menstrual cycle.

Hypericum - St. John's Wart
Hypericum is a homeopathic remedy that helps heal nerve pain. It is especially useful when there is numbness or tingling in the extremities, or radiating pain from one area to another. Hypericum is useful for the unbearable prickly pain that radiates along nerve pathways, is worse with movement, and worse when touched. Hypericum is the Latin name of St. John's Wort, and can be beneficial when depression is an associated symptom of FM.

There are other homeopathic remedies that may more appropriately fit different specific symptoms of the client and by referring to homeopathic books or practitioners you may get better results. Homeopathic remedies are also available in formulas of two or more substances mixed together. Formulas are a more user-friendly way to use homeopathic medicines since the indications for their use are extremely clear. The use of several remedies combined in formulas provides a broad effect not available in a single remedy.

Use only one remedy, whether in a formula or as a single remedy, at a time. Single remedies are recommended when the specific symptoms are known, and when a higher potency of a remedy is desired but not available in a formula. Formula products usually contain remedies in the 3x, 6x, or 12x potencies, while people with severe pain may receive more rapid benefit from the 30c potency. Two hundred years of homeopathic clinical experience has found that the higher the potency, the more deeper and faster the medicine acts. However, the higher the potency used, the more accurate the remedy must fit the FM client. Because of this, it is recommended to use the 30c potency when the user is very confident that the remedy picked is the correct one. The use of lower potencies, such as the 6th or 12th potency, is indicated when general symptoms are used to find the remedy, or you can consider using a homeopathic formula.

When taking homeopathic remedies, it is recommended to discuss ALL that you're taking with your doctor. With homeopathy, taking more pellets is not recommended, but increasingthe frequency of the remedy may be needed to get the full effect of low potency remedies. At first, when there is the greatest amount of pain and discomfort, the remedy may need to be taken every hour. Usually after four doses, the frequency can be reduced to every two hours. As the intensity of pain diminishes, taking a dose every four hours is common. If no improvement is noticeable after a few days, it is not recommended to take further doses of the same remedy.

Although most homeopathic remedies are in pill form for internal use, there are a select number of homeopathic remedies that are available in external applications. Some external applications are in ointments, gels, or sprays. Although they have a similar degree of effectiveness, each has certain benefits and detriments.

Homeopathic remedies must be considered as an integral part in creating a protocol to reduce FM symptoms. The use of these remedies will reduce stress held in the muscle tissues, and will allow the pain to be relieved in a shorter period of time. The relief of pain that homeopathic remedies can provide will make it easier to create more lifestyle changes, since you will feel better and have more energy.

Hyperbaric Oxygen Therapy

Hyperbaric oxygen treatments infuse the body with oxygen, increasing O2 levels by up to 1000% in body tissues through the increased pressure. This oxygenation of the tissues allows better functioning of organ systems and has been shown to lessen pain and increase movement and flexibility in chronic pain patients. Viruses are unable to survive in the presence of abundant oxygen, therefore a significant "die-off" of viruses and bacteria is experienced when undergoing hyperbaric treatments. Hyperbaric therapy also acts as an immune modulator and allows organ and gland functionality to normalize, reducing many debilitating symptoms. Because the chambers pressurize the atmosphere, hyperbaric acts as a detoxifier as well. By forcing oxygen into the tissues through this pressure, toxins, chemicals and other impurities are forced out.

Hyperbaric oxygen is not a cure; but it does help patients to feel better and do more, and this often revives their desire to do even more. Hyperbaric Oxygen Therapy is a safe, effective method of delivering increased oxygen to the body's cells, tissues, organs, and fluids.

• Breathing oxygen in a hyperbaric chamber gives us up to a 400% increase from the amount of oxygen available in normal air.


• Hyperbaric oxygen therapy dissolves oxygen directly into the plasma, brain and cerebrospinal fluids.


• The increased pressure causes the blood plasma and other liquids of the body to absorb MUCH LARGER QUANTITIES of oxygen, greatly increasing oxygen uptake by the cells, tissues, glands, brain, other organs, and fluids of the body.


• The resulting increased uptake of oxygen allows for increased circulation to areas that may have swelling or inflammation. At the same time, the increased pressure decreases the swelling and inflammation.


• Oxygen is then utilized by the body for vital cell functions. Healthier cells equals healthier tissues, organs, and bodily functioning.

Intravenous Micro Nutrient Therapy

Intravenous Micronutrient Therapy, or IVMT, is a treatment method which uses nutrients such as vitamins or minerals and administers these directly into the bloodstream rather than taking these nutrients as oral supplements which is more common. There are several advantages of giving the body nutrients by the intra-venous method.

First, by injecting substances directly into the bloodstream you eliminate any alteration in the nutrients which may occur from the actions of digestive enzymes. Second, the amount of nutrients in the blood can reach much higher, more therapeutic levels faster than is possible by absorbing nutrients through the Gastro-Intestinal system. This may be particularly important if a patient is suffering from a GI system disorder where absorption of nutrients is impaired. In some cases the IV use of micronutrients permits much higher levels than are possible even with a healthy GI system.

The substances used in IVMT are vitamins and minerals which are categorized as "Essential Nutrients" - those things our bodies must have in order to be healthy or even survive, but are incapable of making from other raw materials. Traditionally, Essential Nutrients were obtained from the food we eat. In modern times, however, the poor quality of our over-processed foods means that most of us are severely deficient in these Essential Nutrients. Deficiencies of these nutrients, in fact, are associated with most chronic illnesses. Providing the body with Essential Nutrients it badly needs is generally healthy for most people. Small risks are associated with the intravenous injection process, which may include bruising around the injection site, and are similar to the risks of having your blood drawn for lab tests.

Side Effects of treatment can include bruising around the site of the needle stick. Some patients may have a tendency to vascular fragility, and can suffer a phenomenon known as "infiltration", in which the walls of the vein rupture and the IV fluid leaks into the surrounding tissue causing local burning. This will dissipate within a short period of time, but the IV site will need to be moved to another vein. Some patients may have small or hard-to-find veins. In rare instances, if you have small veins or are especially prone to vascular fragility, you may not be a candidate for IVMT. In some instances, a period of high dose oral nutrients can build up your nutritional state and help strengthen your veins to the point you can use the IVMT therapy.

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases well-being, and, over time, reduces fatigue and pain. Many studies have also demonstrated that exercise can improve physical and emotional function, as well as reduce symptoms, including pain.

Programs often combine aerobic, strength-training, and flexibility exercises with self-management education. Some studies have shown improvements lasting for up to 9 months after the exercise program ends.

Types of exercise that have been beneficial to people with Fibromyalgia are:

• Graded Exercise: A very gradual program of activity, beginning with mild exercise and building in intensity over time.


• Stretching exercises before working out. A daily stretching routine can help relax tense muscles and prevent soreness.


• Walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water therapy are good because they don't require putting weight on the joints.


• Tai Chi Benefits for Fibromyalgia and CFS/ME.

Patients who try difficult exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but they should not get discouraged. Patients who do not respond to one type of exercise might consider experimenting with another form.

Massage Therapy

Though it may seem like a new technique, massage therapy has actually been around for a long time. In fact, ancient Egyptians painted pictures of people receiving massages on the inside of their tombs. Massage therapy has been used to treat physical and psychological ailments for some time. It is even believed that Julius Cesar received daily massages for neuralgia.

Massage therapy is a hands-on treatment that is becoming more and more popular, both with fibromyalgia patients and other pain sufferers. In massage therapy, your muscles and soft tissues are manipulated in order to relieve stress, reduce pain, and increase flexibility. Usually done with the hands, there are a variety of different techniques used to give a massage. Common techniques involve stroking, kneading, and palpating the muscles. Sometimes, a special instrument or device is used to help relieve tension in tight muscles. Hot and cold therapies are also used during massages in order to increase blood flow and relax muscles.

How Does Massage Therapy Work?

Massage therapy can really reduce the pain, stiffness, and tender points caused by fibromyalgia syndrome. But how does it manage to do this? Well, no one is 100% sure on how massage actually reduces pain, but it may have something to do with the central nervous system. It is theorized that massage therapy actually enhances the production of certain pain blockers, including endorphins, serotonin, and norepinephrine. These hormones work to counteract pain signals conducted by the brain, and this would explain why massage offers such dramatic pain relief.

Benefits of Massage Therapy For Fibromyalgia Sufferers

Massage therapy is actually one of the most beneficial treatments for fibromyalgia pain and fatigue. In fact, in a survey completed by fibromyalgia sufferers, massage therapy was rated the best fibromyalgia treatment option by an overwhelming margin. Massage therapy benefits include:

• increased blood circulation to the muscles, allowing for faster muscle repair
• increased flexibility
• increased range of motion
• decreased stress and depression
• reduced pain
• reduced stiffness
• improved sleep patterns

In a 1996 study, fibromyalgia sufferers reported a 38% decrease in pain symptoms after receiving just ten, 30 minute massage sessions. They also reported a significant decrease in their sleep difficulties: they began sleeping for longer periods at a time and were disturbed less by sleep disorders.

Types of Massage Therapy

There are a variety of different kinds of massages that are on offer by your massage therapist. Some of the most popular massages include the Swedish massage and the deep tissue massage. Other types of massage include myofascial release, shiatsu, and reflexology. Here are a few types of massage that you may find beneficial for relieving your fibromyalgia pain.

Swedish Massage

Swedish massage is one of the most popular forms of massage used in North America. The Swedish massage technique is designed to increase the amount of oxygen that is delivered to the muscles. This helps to flush out toxins and improve the flexibility and health of your muscles. Swedish massage is characterized by long, gliding movements, which involve stroking the body with the thumbs, fingertips, and palms. However, Swedish massage also makes use of kneading and tapping techniques, and uses vibration to benefit the body.

Deep Tissue Massage

Deep-tissue massage is a vigorous therapy used to loosen areas of hardened or inflexible muscles and tissues. It targets the deep layers of your muscles and tendons, helping to release tension and chronic muscle pain. Deep, pressurized strokes are usually made along or across the muscles. Because deep tissue massage uses slower and deeper strokes than Swedish massage therapy, you may feel a little pain immediately following your treatment. However, this pain should disappear within a day or so.

Myofascial Release

Myofascial release techniques help to relieve stiffness and tightness in your body's fascia, caused by myofascial pain. The fascia is a thin layer of tissue that covers all of your muscles and organs. In fibromyalgia, sometimes the fascia can become extremely short and tense, resulting in pain. Myofascial release therapy uses stretching techniques to relieve this pain. The therapist first locates an area of tightness on your body. He gradually stretches this area, holds the stretch, and then allows the fascia to relax. The process is repeated until the fascia is completely relaxed.

Please note that this is just a list of known commonly used medications that have been used to treat various FM symptoms. It is not to be considered as complete or a recommendation by FM/CFS/ME RESOURCES. It also does not replace the advice and treatment from your doctor or medical professional which we strongly urge the FM sufferer to obtain.

• Sleep Medications
• Analgesics
• Muscle Relaxants
• Tricyclic Antidepressants

• Selective Serotonin Reuptake Inhibitors
• Anti-Seizure Medications
• Dopamine Agonists
• Investigational Medications

• Ambien®
• Lunesta®
• Klonopin®
• Desyrel®

A number of analgesics are used to treat the pain symptoms resulting from FM, including nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, and tramadol.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed medications for the inflammation of arthritis and other body tissues, such as in tendinitis and bursitis. Examples of NSAIDs include:

NSAID's

• aspirin (Bayre®, Aspiritab®)
• naproxen (Aleve®)
• ibuprofen (Advil®, Motrin®)
• Voltaren® (dicofenac)
• Orudis® (keoprofen)
• Lodine® (etodolac)
• Daypro® (oxaprozin)
• Toradol® (ketorolac)
• Naprosyn® (naproxen)

Opioids

Opioids (narcotic medication) drugs are used to treat intermittent flares of pain that can occur even though a person is taking analgesic medications on a fixed schedule for pain control. These severe flares of pain are called breakthrough pain because the pain "breaks through" the regular pain medication.

• morphine
• codeine
• oxycodone (OxyContin®)
• propoxyphene (Darvon®)
• hydrocodone (Vicodin®)
• hydromorphone (Dilaudid®)
• meperidine (Demerol®)

Note: To date, FM has not been found to be an inflammatory disorder. It is the pain relieving property that is considered useful commonly used medications to treat FM sufferers. It is not uncommon for this class of drugs to cause stomach irritation which can increase in severity the longer you take the medication.

Cox-2 inhibitors

COX-2 inhibitors are newly developed drugs for inflammation that selectively block the COX-2 enzyme. Blocking this enzyme impedes the production of the chemical messengers (prostaglandins) that cause the pain and swelling of arthritis inflammation. Cox-2 inhibitors are a new class of nonsteroidal anti-inflammatory drugs (NSAIDs). Because they selectively block the COX-2 enzyme and not the COX-1 enzyme, these drugs are uniquely different from traditional NSAIDs. Examples of Cox-2 inhibitors include:

• Vioxx® - withdrawn from the U.S. market in 2004
• Bextra® - withdrawn from the U.S. market in 2005
• Celebrex® (Celecoxib)
• Tramadol (Ultram®)

Muscle Relaxants

Muscle Relaxants minimize muscle spasms and muscle pain. They are usually taken at bed time due to their sedating qualities. Side effects include drowsiness, constipation, headache, dry mouth, and heart palpitations. * Soma has an additional risk of becoming habit forming.

• Robaxin® (methocarbamol)
• *Soma® (carisoprodol)
• Skelaxin® (metaxalone)
• Norflex® (orphenadrine citrate)
• Flexeril® (cyclobenzaaprine hydroclhloride)

Tricyclic Antidepressants

Tricylcic Antidepressants increase the levels of the brain's nero-chemical serotonin, help to control pain, and promote sleep. Side effects include dry mouth, drowsiness, morning hangover, constipation, weight gain and occasionally anxiety. Tricylcic's are usually taken at bedtime because of their sedating qualities. The following medications are examples of tricylcic antidepressants:

• Desyrel® (trazadone)
• Pamelor® (nortriptyline)
• Elavil® (amitriptyline)
• Sinequan® (doxepin)

Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors (SSRI's) boost serotonin levels but also help to keep serotonin available longer in the system after it has been secreted by the brain. These medications can help manage fatigue, cognitive impairment, and depression and are often taken in the morning. Side effects include nervousness, insomnia, dry mouth, headache, diarrhea and nausea. Paxil and Zoloft have sexual dysfunction as their side effect. The following medications are examples of SSRI's:

• Zoloft® (sertaline)
• Prozac® (fluoxetine)
• Serzone® (nefazodone)
• Paxil® (paroxetine)
• Celexa® (citalopram hydrobromide)

Anti-Seizure Medications

Anti-seizure drugs are also sometimes used. Pregabalin, originally used for the nerve pain suffered by diabetics, has been approved by the American Food and Drug Administration for treatment of fibromyalgia. A randomized controlled trial of pregabalin 450 mg/day found that a number needed to treat of 6 patients for one patient to have 50% reduction in pain. The following are some of the anti-seisure medications used in the treatment of Fibromyalgia:

• lorazepam (Ativan®)
• Depakote®
• Dilantin®
• clonazepam (Klonopin®)
• gabapentin (Neurontin®)
• pregabalin (Lyrica®)
• Phenobarbital®
• carbamazepine (Tegretol®)
• topiramate (Topamax®)
• clorazepate (Tranxene®)

Dopamine Agonists

Dopamine agonists (e.g. pramipexole (Mirapex) and ropinirole(ReQuip)) have been studied for use in the treatment of fibromyalgia with good results. A trial of transdermal rotigotine is currently on going. The following are examples of Dopamine Agonists:

• bromocriptine (Parlodel®)
• cabergoline (Permax®) - Removed from market March 29,2007
• pramipexole (Mirapex®)
• ropinirole (Requip®)
• apomorphine (Apokyn®)
• rotigotine (Neupro®)

Investigational Medications

Dextromethorphan
Dextromethorphan is an over-the-counter cough medicine with activity as an NMDA receptor antagonist. It has been used in the research setting to investigate the nature of fibromyalgia pain however, there are no controlled trials of safety or efficacy in clinical use.

Cannabis
Fibromyalgia patients frequently self-report using cannabis (medical marijuana), therapeutically to treat symptoms of the disorder. Writing in the July 2006 issue of the journal Current Medical Research and Opinion, investigators at Germany's University of Heidelberg evaluated the analgesic effects of oral THC (?9-tetrahydrocannabinol) in nine patients with fibromyalgia over a 3-month period. Subjects in the trial were administered daily doses of 2.5 to 15 mg of THC, but received no other pain medication during the trial. Among those participants who completed the trial, all reported a significant reduction in daily recorded pain and electronically induced pain.

Guaifenesin
Among the more controversial therapies involves the use of guaifenesin; called St. Amand's protocol or the guaifenesin protocol the efficacy of guaifenesin in treating fibromyalgia has not been proven in properly designed research studies. Indeed, a controlled study conducted by researchers at Oregon Health Science University in Portland failed to demonstrate any benefits from this treatment, and the lead researcher has suggested that the anecdotally reported benefits where due to placebo suggestion. The results of the study have since been contested by Dr St. Amand, who was a co-author or the original research report.

Topical Medications

There are various types of topical medications, the following are just a brief example:

• Duragesic®
  Duragesic (fentanyl skin patches, pain patches) contain the generic drug Fentanyl. Duragesic® is a narcotic painkiller used for severe pain relief. Patches release the narcotic medicine through the skin which regulates and helps act as a time release mechanism. Duragesic® patches are used to treat severe and chronic pain. Caution is urged, as this medication can cause nausea or vomiting.


• Lidoderm®
  Lidoderm patches are comprised of an adhesive material containing 5% lidocaine, which is applied to a non-woven polyester felt backing and covered with a polyethylene terephthalate (PET) film release liner. The release liner is removed prior to application to the skin. The size of the patch is 10 cm x 14 cm. This type of patch can cause skin irritation. This type of drug requires careful management by a physician due to its possibility to cause addiction.


• Biofreeze®
  Products contain Ilex, an herbal extract from a South American holly shrub. Ilex is used around the world in various health & wellness formulations. Biofreeze® topical analgesic does not use waxes, oils, aloe or petroleum. The result is a fast-acting, penetrating, long lasting pain reliever. This product comes in a roll-on, spray, or lotion. Biofreeze® is said to be extremely effective in helping people who have trouble sleeping due to nagging pain & discomfort.



• Capsaicin® (Capzasin-P®, Icy Hot®, Rid-a-Pain®, Zostrix®)
  This product is used to help relieve pain in the muscle or joints. It is also used for different types of nerve pain, such as pain due to nerve problems in people with diabetes. Researchers have found that capsaicin appears to work by "reducing substance P which is found at nerve endings and is involved in transmitting the pain signal to the brain." Clinical studies are emerging which indicate capsaicin cream is more effective than placebos in treating post-surgical neuropathic pain.


• Voltaren Gel®
  This product is the first prescription topical treatment for osteoarthritis that has been approved by the Food and Drug Administration. Voltaren Gel, a nonsteroidal anti-inflammatory medication in topical form, will mostly be used on knees and hands. Voltaren Gel should not be used by patients with known hypersensitivity to diclofenac. It also should not be used by patients who developed asthma, urticaria, or allergic reactions after taking aspirin or NSAID's. Voltaren Gel should also not be used by patients who had coronary artery bypass surgery in order to treat perioperative pain.

Occupational Therapy

Occupational therapy (OT) is rehabilitation of mentally and physically disabled persons by teaching them a skill or providing them with creative activity. OT gives people the "skills for the job of living" necessary for living meaningful and satisfying lives.

People who run occupational therapy programs are called occupational therapists. Occupational therapists have the job of helping you to become more successful in your daily functioning. These therapists will assist you in finding ways to reduce your FM symptoms, and will help you to increase your ability to perform all sorts of different tasks. They will also help you manage the emotional and mental challenges that come with FM.

Occupational therapists believe that real health can only be found when there is a balance of work, recreation, and rest in your life. By assessing your home and work environments, your occupational therapist can provide suggestions on how you can better function and achieve health and independence. Occupational therapists are also capable of providing stress management tips, symptom reduction tips, and coping strategies to help you improve the quality of your life.

Osteopathic Manipulative Medicine

Osteopathic Manipulative Medicine is a type of "hands-on" medical treatment based on an in-depth understanding of the musculoskeletal, circulatory, lymphatic and nervous systems of the body used by Doctors of Osteopathic Medicine (D.O.'s). Doctors of Osteopathic Medicine are fully-trained, fully-licensed medical doctors who complete premedical undergraduate courses, 4 years of medical school, and 3 years or more of residency training in their chosen specialties after medical school. They must be fully licensed in their respective states before they can practice medicine.

Osteopathic Physicians (D.O.'s) can diagnose and treat all conditions (like M.D.'s), perform surgery (like M.D.'s), and prescribe all medications (like M.D.'s), but they are additionally trained in Osteopathic Manipulative Medicine (unlike M.D.'s).

Osteopathic Manipulative Medicine is not the same thing as chiropractic treatment (chiropractors do not go to 4 years of medical school and are not licensed as medical doctors). It is also not the same thing as massage (massage therapists also do not go to medical school for 4 years, and are not licensed to practice medicine).

Physical Therapy

Physical therapy (or physiotherapy) is the provision of services to people to develop, maintain and restore maximum movement and functional ability throughout the life span. It includes the provision of services in circumstances where movement and function are threatened by the process of aging or that of injury or disease. The method of physical therapy sees full and functional movement as the heart of what it means to be healthy.

In some cases, doctors may refer people with FM to a physical therapist, either to design an exercise program or to treat particularly painful flares. Physical therapists employ several techniques. For example, in "spray and stretch," a physical therapist sprays the sore region with ethyl chloride to anesthetize it before stretching the patient's muscles.

While there is no known cure for fibromyalgia, physical therapy may help ease the symptoms of pain. It can also help reduce stiffness and fatigue. In addition to exercise, physical therapists use a wide range of resources - from deep tissue massage to ice and heat packs for hydrotherapy. With these tools, physical therapists can help people with fibromyalgia use their muscles, stretch for flexibility, and move their joints through range-of-motion exercises.

The benefit of physical therapy is that it allows a person with fibromyalgia to work closely with a trained professional who can design a fibromyalgia-specific treatment program. The therapist documents your progress and gauges whether you're practicing good therapy habits, alignments, and movement patterns when doing "homework" or exercises at home.

The ultimate goal of physical therapy is for you to learn the specific exercises and then do them daily at home.

Hydrotherapy with moist heat or cold packs works by stimulating your body's own healing force. For instance, cold compresses reduce swelling by constricting blood vessels. Conversely, warm, moist compresses on painful areas dilate blood vessels. That increases the flow of blood, oxygen, and other nutrients and speeds the elimination of toxins.

Hydrotherapy works well for almost all types of pain, including fibromyalgia pain. Cold compresses may reduce the pain of an injury, such as a sprain or strain. Moist heat may give relief to fibromyalgia's chronic muscle pain or trigger point pain. You may use a moist heating pad, a warm, damp towel, or a hydrocollator pack. You can also stand or sit on a stool in the shower and let warm water hit the painful area on your body.

Your physical therapist may recommend that you use moist heat for a few minutes just before and after stretching or doing resistance or aerobic exercise. Doing so will make the exercise less painful and more effective. If you want to use moist heat to decrease fibromyalgia pain, you might try it twice daily, about 15 minutes each time. Some people with fibromyalgia prefer alternating the ice compresses with the moist heat to get the most benefit.

What Other Tools Does a Physical Therapist Use for Fibromyalgia?

The physical therapist may use different types of tools with fibromyalgia patients including:

• deep tissue massage
• low-impact aerobic conditioning (water aerobics)
• pain relief exercise
• stretching and strengthening exercises
• TENS units (transcutaneous electrical nerve stimulation)
• ultrasound

Relaxation Techniques

Relaxation techniques are used by people who wish to relax, for a wide variety of reasons. Since the 1960s, research has indicated strong correlations between stress levels and physical and emotional health. Meditation was among the first relaxation techniques shown to have a measurable effect on stress reduction.

Relaxation techniques are a quieting of the sympathetic nervous system. They result in a decrease in blood pressure, heart rate and oxygen consumption. There are many techniques which have been used over centuries which can induce the relaxation response.

They include:

• Focused breathing
• Progressive Muscle Relaxation
• Guided Imagery
• Autogenic Training
• Meditation
• Self-hypnosis

All these techniques have two simple steps in common:

1. Focusing one's mind on a repetitive phrase, word, breath or action
2. Adopting a passive attitude toward the thoughts that go through one's head

Extensive research has shown that regular practice of relaxation techniques bring about a decrease in the responsiveness of the sympathetic nervous system. In addition to the immediate results of decreasing heart rate, blood pressure, breath rate, and oxygen consumption, regular practice over a month or more seems to lead to a change in how the body responds to adrenaline. Research suggests that there are decreases in anxiety and depression, and an enhanced ability to cope with life stressors, after regular practice of relaxation techniques.

Relaxation techniques are not to be confused with feelings of relaxation one may experience after reading a good book, watching TV, or listening to music. While those activities may be enjoyable, they do not result in either the immediate or long term physiological changes associated with relaxation techniques. While relaxation techniques are a natural response of the body, it is only truly effective after a person is specifically trained and regularly practices these techniques.

TENS Unit

"TENS" is the acronym for Transcutaneous Electrical Nerve Stimulation. A "TENS unit" is a pocket size, portable, battery-operated device that sends electrical impulses to certain parts of the body to block pain signals.

The electrical currents produced are mild, but can prevent pain messages from being transmitted to the brain and may raise the level of endorphins (natural pain killers produced by the brain).

TENS units should only be used under the direction of a doctor or physical therapist. Electrodes are attached to the surface of the skin over or near the area where you are experiencing pain. It is important that you learn how to:

• correctly put on the electrodes (proper placement is important)
• operate the unit
• change the batteries
• vary the controls and settings (both the frequency and voltage)
• set the proper duration and intensity of the stimulation (which depends on the location and type of pain)

TENS units are prescribed for both acute pain and chronic pain conditions such as:

• arthritis
• joint pain
• fibromyalgia

For some chronic pain patients, a TENS unit provides pain relief that can last for several hours. For others, a TENS unit may help reduce the amount of pain medications needed. Some patients hook the unit onto a belt turning it on and off as needed.

The cost of a TENS unit can range from about $100 to several hundred dollars. TENS units can be purchased or rented. A prescription usually is necessary for insurance reimbursement of a TENS unit.

Technique of Trigger-Point Injection

Trigger-point injection can effectively inactivate trigger points and provide prompt, symptomatic relief.

Increased bleeding tendencies should be explored before injection. Capillary hemorrhage augments post injection soreness and leads to unsightly ecchymosis. Patients should refrain from daily aspirin dosing for at least three days before injection to avoid increased bleeding.

The patient should be placed in a comfortable or recumbent position to produce muscle relaxation. This is best achieved by positioning the patient in the prone or supine position. This positioning may also help the patient to avoid injury if he or she has a vasovagal reaction.

The choice of needle size depends on the location of the muscle being injected. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. A 22-gauge, 1.5-inch needle is usually adequate to reach most superficial muscles. For thick subcutaneous muscles such as the gluteus maximus or paraspinal muscles in persons who are not obese, a 21-gauge, 2.0-inch needle is usually necessary. A 21-gauge, 2.5-inch needle is required to reach the deepest muscles, such as the gluteus minimus and quadratus lumborum, and is available as a hypodermic needle. Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue. A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. The needle should be long enough so that it never has to be inserted all the way to its hub, because the hub is the weakest part of the needle and breakage beneath the skin could occur.

An injectable solution of 1 percent lidocaine or 1 percent procaine is usually used. Several other substances, including diclofenac (Voltaren), botulinum toxin type A (Botox), and corticosteroids, have been used in trigger-point injections. However, these substances have been associated with significant myotoxicity. Procaine has the distinction of being the least myotoxic of all local injectable anesthetics.

Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable. Using sterile technique, the needle is then inserted 1 to 2 cm away from the trigger point so that the needle may be advanced into the trigger point at an acute angle of 30 degrees to the skin. The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle. The application of pressure also helps to prevent bleeding within the subcutaneous tissues and the subsequent irritation to the muscle that the bleeding may produce. The serious complication of pneumothorax can be avoided by refraining from aiming the needle at an intercostal space.

Before advancing the needle into the trigger point, the physician should warn the patient of the possibility of sharp pain, muscle twitching, or an unpleasant sensation as the needle contacts the taut muscular band. To ensure that the needle is not within a blood vessel, the plunger should be withdrawn before injection. A small amount (0.2 mL) of anesthetic should be injected once the needle is inside the trigger point. The needle is then withdrawn to the level of the subcutaneous tissue, then redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction until the local twitch response is no longer elicited or resisting muscle tautness is no longer perceived.

Post-injection Management: After injection, the area should be palpated to ensure that no other tender points exist. If additional tender points are palpable, they should be isolated, needled and injected. Pressure is then applied to the injected area for two minutes to promote hemostasis. A simple adhesive bandage is usually adequate for skin coverage.

Vitamins & Supplements

Many doctors, researchers and people with FM and CFS/ME say vitamin supplements are an important part of managing your symptoms. Some vitamins have gone through double-blind, placebo controlled clinical trials and have had mixed results, while others haven't been scientifically tested.

Here are seven things you should know about supplements for FM and CFS/ME:

1. Supposed Cures

Many websites claim to sell natural "cures" or treatments for FM and CFS/ME that generally are very expensive supplement formulas. While their claims are tempting, remember that nothing is proven to cure these conditions, and few things - natural or otherwise - are even proven to alleviate symptoms. Be sure to research any substance you consider using and always involve your doctor in your decisions and in follow-up care.


2. Beliefs About Supplements

While definitive evidence is lacking, many experts on FM and CFS/ME claim vitamins can help alleviate common nutritional deficiencies; boost energy, alertness and cognitive function; and decrease pain.


3. Risks

Dietary supplements generally are better tolerated and have fewer risks than prescription medications, but anything you take to change the way your body functions is considered a drug. Just because a product is natural doesn't mean it's safe and won't interact with other supplements or medications. You should talk to your doctor and pharmacist about what you're taking, the dosages, and potential interactions. If you have sensitivities to foods, especially gluten, you need to be aware of what inert ingredients are in the vitamins you take.


4. Testing

Your doctor may want to test you for certain deficiencies that may be commonly associated with FM and CFS/ME or that could be contributing to your specific symptoms. This could help guide your supplement therapy and dosages. If your doctor is concerned about severe deficiencies or absorption problems, he/she may give you prescription-level doses or injections rather than over-the-counter (OTC) vitamins.


5. Disagreements

Not all doctors agree on whether these conditions are associated with deficiencies or malabsorption problems. If you're concerned about these issues, you may want to bring them up. Even if your doctor doesn't fully support a regimen you'd like to follow, work together to ensure that you're not damaging your health in your quest to feel better.


6. What To Expect

If you do opt to use supplements as part of your treatment regimen, you shouldn't expect miraculous results. Also, as with medications and other therapies for FM and CFS/ME, you'll probably have to experiment with different combinations to come up with the supplement regimen that works for you.


7. Getting Started

When starting supplements, it's important to only start one new one at a time, then wait a week or two before introducing another one. That will give you a chance to see what effect each supplement has on your body. The same goes for discontinuing them (unless you develop an allergy or other negative side effect.)

Supplements doctors frequently recommend include:

• Vitamin B12
• NADH & CoQ10
• Vitamin D

• Magnesium Malate
• DHEA
• Carnitine

B vitamins are essential for energy production, and some research shows that the majority of people with FM & CFS/ME are low in B12. Some experts on these illnesses recommend at least 50 mg daily of most B vitamins, and 500 micrograms of B12. Some treatment protocols use B12 injections.

Many doctors disagree with this and consider B12 injections archaic and unscientific. Some FM and CFS/ME doctors and researchers, however, say anecdotal evidence supports higher B12 levels.

You get B12 in your diet through almost any animal-derived food. Some vegetarian products are fortified with B12, since a plant-based diet generally will not contain enough.

NADH, or reduced nicontinamide adenine dinucleotide, is synthesized from niacin and is contained in all living cells. You can get it through your diet by eating meat, fish and poultry, and it's also available in supplement form. Research shows that NADH can stimulate brain function.

CoQ10, or coenzyme Q10, is a powerful antioxidant that is in most of the tissues in your body. You can get it through supplements or foods including oily fish, organ meats and whole grains.

NADH and CoQ10 both are coenzymes, which means they help enzymes in your body break down food and convert it to energy in the form of adenosine triphosphate (ATP), which studies show is sometimes deficient in people with FM or CFS/ME. Early research on these supplements for treating FM and CFS/ME is promising, but more research needs to be done.

Your body needs vitamin D to help with calcium absorption and for bone growth and strength. It's naturally available in eggs, Swiss cheese, and several fish, including salmon, mackerel, tuna and sardines. You also get it from sunshine. Food makers also add it cereal and milk to help prevent rickets in children. Along with calcium, vitamin D protects you from osteoporosis.

Symptoms of vitamin D deficiency include muscle pain and weakness. Studies show that many people with FM or CFS/ME - more than 25% - have low vitamin D levels, and that supplementation may help lower pain levels in some cases. One study shows that vitamin D-deficient people need twice as much narcotic pain reliever non-deficient people.

Some FM and CFS/ME experts recommend between 1,000 to 2,000 IU of vitamin D daily, which far exceeds the FDA's recommended daily allowance. In fact, the National Institutes of Health considers 2,000 IU the highest tolerable daily amount.

It's important that you include your doctor in any decisions regarding vitamin D supplementation. Too much vitamin D is considered potentially toxic and can lead to nausea, vomiting, poor appetite, constipation, weakness and weight loss. If you take high levels of vitamin D, your doctor may want to test your levels periodically.

Magnesium is a mineral found in fish, artichokes, bananas, grains, yogurt, black beans, almonds, cashews and brazil nuts. Malate, or malic acid, comes from apples or other tart fruits. Both of these substances help produce energy in the form of adenosine triphosphate (ATP), which studies show is sometimes deficient in people with FM or CFS/ME. Magnesium is vital to cell formation and helps maintain muscles, bones and nerves.

Some research supports adding magnesium and malate, either separately or together as magnesium malate, for boosting energy and alleviating pain and tenderness in people with FM. A study released in 2008 suggested low magnesium levels were a predictor of fatigue in FM. One study, however, showed taking magnesium supplements was no more effective than a placebo. Still, many doctors and patients swear by it, and more research is needed to confirm the findings both for and against magnesium malate.

DHEA stands for dehydroepiandrosterone. This steroid occurs naturally in your body, where it's produced by the ovaries and the adrenal glands. Your body uses it to make some hormones, including estrogen and testosterone. Your DHEA levels drop as you age, and this is considered a key marker in determining biological age. In women, DHEA levels may increase during times of stress, and DHEA may also be involved in immunity.

Studies show that, as a supplement, DHEA can help people with adrenal insufficiency and depression, which are common in people with FM and CFS/ME, and for treating autoimmune conditions such as lupus and multiple sclerosis, which have a lot of symptoms in common with FM and CFS/ME.

In double-blind, placebo-controlled clinical trials of post-menopausal women with FM, however, DHEA did not seem to reduce pain, fatigue or functional impairment, nor did it improve quality of life, cognitive function or mood. For CFS/ME, scientific evidence so far is unclear as to whether DHEA can help alleviate symptoms. Still, many doctors say they have seen it work in their patients.

We don't have studies yet on the long-term effects of DHEA, but because it may cause high levels of some hormones, experts say it could theoretically raise your risk of prostate, breast or ovarian cancers, as well as other cancers that are hormone sensitive. DHEA is a steroid, and steroid use can be very dangerous. Any DHEA use should be discussed with and monitored by your doctor.

Like so many of the supplements used to treat FM and CFS/ME, carnitine (also called L-carnitine) helps your cells with energy production. It does this by helping your body break down fat and convert it to energy.

Carnitine deficiency can cause symptoms including muscle pain, extreme fatigue, hypoglycemia (low blood sugar), confusion, depression, and cardiomyopathy (when the heart lacks pumping power or doesn't fill with blood correctly.) Your doctor can test you for carnitine deficiency.

Studies show that carnitine supplementation can help lower pain levels and boost the mental health of people with FM, and can lessen fatigue in those with CFS/ME. Researchers also found that people with either condition tolerated carnitine well.

Still, if your carnitine levels get too high, you can develop side effects. Serious ones include rapid heart rate, increase in blood pressure, and fever. Less serious ones can be vomiting, nausea, headache, diarrhea, stuffy nose, restlessness and difficulty sleeping (especially if you take it late in the day.)

Carnitine can impair thyroid hormone action, so you shouldn't take it if your thyroid hormone levels are low or borderline low. It's also not recommended for anyone on dialysis. Carnitine has a higher risk of negative interactions with other supplements, so be sure to talk to your doctor and/or pharmacist about it.