YOU ARE HEADING FOR THE FINAL STATION THE HEALING STATION COMES NEXT ALL ABOARD THE WELLNESS TRAIN! YOU ARE NOW HEADING INTO VICTORY FIBRO WARRIOR - BEFORE YOU GO ON YOUR JOURNEY TO WELLNESS - TAKE SOME TIME TO READ THE FOLLOWING AFFIRMATIONS Positive Self Affirmation Look to this day, For it is life, The very life of life, In its brief course lie all, The realities and verities of existence, The bliss of growth, The splendor of action, The glory of power- For yesterday is but a dream, And tomorrow is only a vision, But today, well lived, Makes every yesterday a dream of happiness And every tomorrow a vision of hope. Look Well, therefore, to this day. -Sanskrit Proverb Nothing in this World is more important than a healthy state of mind. With that, all things are possible. A healthy state of mind compliments any life situation. Affirmations are a powerful way for conditioning the mind to maintain optimum health throughout our entire life. Affirmations are practiced by writing them out on paper, saying them out loud to ourselves, rehearsing them privately in our minds, recording them and playing them back. Here are a few guidelines for practicing Affirmations: Affirm that something is happening here and now. Be careful that you are not affirming something will happen in the future. This is actually a negative affirmation, which says, "Oh, someday I will be rich." Place the results in today, rather than the future. Affirm only the desired result, without placing any hidden reference to undesired things. For example: Affirm that "My relationship is healthy and loving," rather than affirming "My boring relationship is getting better." Affirm what you want, rather than what you want to get rid of. Use the first person, and include your full name in every affirmation sentence. Example: "I, Marnie Alexander, am a happy, healthy, wholesome person." Practice only one or two affirmations at a time, giving them time to work on the subconscious before moving on to other affirmations. Affirmations are like planting seeds. Nourish them with continued energy everyday. Give them time to work, and sprout results. Be open to creative ways that affirmations manifest results. Affirmations are practiced by repetition, and are done everyday. Repetition produces results, excuses don't. Write them out ten or twenty times each morning and each evening. Record and play them back while exercising, working, driving. Paste them on notes around your house. Rehearse them in your mind when challenged by a difficult situation. Cultivate What You Want To Grow. Work with any subconscious fallout from your affirmations, but don't quit doing the affirmation. Positive mind conditioning can cause all sorts of hidden subconscious material to surface. If you begin to experience negative feelings, or stubborn negative thoughts, it means the affirmations are producing results and shaking lose subconscious material. Work with these reactions by ventillating with a trusted person, writing in a personal journal, or seeking guidance. Affirmations For Self Esteem The more I like myself the more others like themselves. I am a happy, healthy, wholesome, beautiful, positive, prosperous person. I am a unique and priceless person, coming from a unique and perfect pattern within me. I am an extremely well liked and pleasing person. I am extremely successful in everything I do and say. I give myself all the permission I need to do what I know is best. I trust and rely upon my excellent sense of judgment in everything I do. I am the best judge of what is best for me, and I trust my judgment completely. I have complete and unconditional worth as a person in this universe. I am fully competent and capable in everything that I decide to do. All of my accomplishments are because I am a fully functioning, capable, competent human being. My worth as a human being is unconditional, and other people unconditionally like me. I am respected and well-liked by all people that I know. I accept and acknowledge unconditionally my individuality and unique personality. I respect myself, I respect all other persons, and all other people respect me. I can trust myself completely as my life unfolds to create my own unique story. I am highly creative, intelligent, attractive, energetic, sexy, witty, smart, healthy, wealthy, and wise. I am an extremely well liked and pleasing person. I am a self determined person, and I allow others the same right. I can say No to other people and know I remain loved and cared for. Other people have the right to say No to me and I know that we still love and care for each other. love and care for each other. I have the right and responsibility to express my anger and remain loved, and I take responsibility to clean up any mess and restore harmony when appropriate. I love myself unconditionally just as I am. GOD'S CHAIR This morning, as soon as my mind woke up, I placed myself in God's arms. The first thing, before I was barely awake, I pictured myself climbing up into God's lap, and asking to be held, arms completely around me, embracing me wholly, surrounding my entire body. I can feel myself being accepted without question into a safe place. God's arms reach around me and cover my whole body. I feel comforted. I feel safe from anything and everything that is happening in the world. I am immediately protected from all my fears and worries. I am in the safest place in the world. I relax there and feel the protection, the unconditional acceptance. I go there to escape anything that I am worried about. I go there first thing in the morning when I am feeling that the world is not a safe place. I crawl up into God's lap like a small child gets into the favorite family chair, oversized for the child, sinking deeply into the soft cushion comfort all around me. I am securely enclosed in pillowy comfort. I feel like a child, secure from any expectations. I leave my adultness far behind somewhere, and I have no expectations to figure anything out, nothing I must solve, no problems to fix, no important decisions to make. I am comfortable and secure. God reassuringly embraces me all around my body, as the soft cushiony comfort engulfs me. God gently reminds me that I can stay as long as I like. I feel the peace of being completely protected and taken care of, and I stay as long as I like. Differential Diagnosis The diagnosis of Fibromyalgia may be made based on the ACR criteria or based on the presence of the characteristic syndrome, or both. Clinicians familiar with Fibromyalgia order a minimum of testing when cases appear straightforward. The thyroid-stimulating hormone level should be checked routinely because hypothyroidism can mimic the symptoms of Fibromyalgia. Other diagnoses to consider include drug-induced Myopathies (particularly those associated with the statin class of lipid-lowering agents), Polymyalgia rheumatica and other Rheumatologic syndromes. Myofascial pain syndrome may be confused with Fibromyalgia. To complicate the situation, myofascial pain syndrome may occur in patients with Fibromyalgia. Similar to Fibromyalgia, myofascial pain syndrome is a condition that is diagnosed clinically. With a careful history and physical examination, the physician should be able to determine whether a patient has Fibromyalgia, myofascial pain syndrome, or both. While the pain of Fibromyalgia is widespread with changing areas of emphasis, myofascial pain arises from trigger points in individual muscles. The diagnosis of myofascial pain syndrome should be considered when, by history, the patient's pain pattern is limited to a particular region over time. The definitive differentiation between myofascial pain syndrome and Fibromyalgia is made by physical examination. Myofascial pain syndrome is defined by the presence of trigger points. Unfortunately, location alone does not differentiate between trigger points and tender points because they often occur in similar locations. Distinguishing between trigger points and tender points depends on characteristic findings associated with trigger points that are found on physical examination. Trigger points are located within taut bands of muscle, whereas tender points are not. Palpation of trigger points often reproduces the pain radiation pattern experienced by the patient and can elicit a twitch in the muscle. The pain elicited on palpation of a tender point is localized to the area under palpation and does not elicit a jump or twitch. Lastly, trigger points often have a nodular texture described as similar to a pencil eraser, whereas tender points have no palpatory characteristics distinguishing them from surrounding tissue. Comorbid Conditions Patients with Fibromyalgia often have one or more comorbid conditions. Along with myofascial pain syndrome, the most common of these are migraine headache, irritable bowel syndrome and a history of depression and chronic fatigue. Although treatment for Fibromyalgia may help to alleviate the symptoms of comorbid conditions, specific treatment for these comorbidities may be indicated. Treatment Because the symptoms of Fibromyalgia wax and wane, treatment (as with that of other chronic diseases) is an ongoing process rather than management of a single episode. Flare-ups often exacerbate the patient's underlying stress. Furthermore, stress can also precipitate flare-ups of Fibromyalgia. Physicians should spend some time eliciting and hearing the ongoing narrative of the struggle of living with a chronic disease and attempt to ameliorate the effects of the symptoms on the patient's quality of life. Treatment of Fibromyalgia is largely empiric. Although some frequently used approaches, such as antidepressants and exercise, have evidence to support their use, others (such as acupuncture) are less well studied. None of the therapies used in Fibromyalgia are based on evidence from larger randomized, double-blind, placebo-controlled trials. This void places a premium on the physician's therapeutic creativity and supportive counseling skills. The therapeutic response to patients with relatively mild symptoms and no sleep disturbances may involve only identification of Fibromyalgia to explain and legitimize their symptoms, along with encouragement to develop and maintain an active exercise program. Physicians should listen to the patient describe the struggle of living with Fibromyalgia and attempt to ameliorate the effects of symptoms on the patient's quality of life. Many patients will benefit from the use of low-dose antidepressants. Other patients may require more complicated regimens, which may include psychotherapy, medications, acupuncture, massage and physical therapy, to maintain function. Ideally, the practitioner will collaborate with the patient to construct a unique treatment plan consonant with the patient's circumstances. That plan will necessarily evolve within the context of the physician-patient relationship. Therapeutic Measures Antidepressant Agents. Although antidepressants have a lengthy history in the treatment of chronic pain syndromes, they have received only limited study in the treatment of Fibromyalgia. The tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or combinations of both, produce mild to moderate improvement in symptoms. In controlled studies, approximately one third to one half of patients responded to pharmacologic treatment. One study found that while 25 mg of amitriptyline (Elavil) or 20 mg of fluoxetine (Prozac) reduced the symptoms of Fibromyalgia, the combination of the two was twice as effective as either agent taken alone. The dosages used are somewhat lower than those needed to treat depression. The older agents (such as Amitriptyline) can be started at a dosage of 10 mg taken daily two to three hours before bedtime. This allows the peak sedative effect to be realized while avoiding unwanted carry-over sedation on awakening. The time of administration can be adjusted depending on individual patient response. The dosage of antidepressant must be individualized. This is particularly true of the tricyclic agents, given their variable absorption, metabolism and excretion. Dosages should be gradually increased, not to exceed the recommended maximum for the drug. Even patients who are able to tolerate very small amounts of these medications may derive benefit from them. In these instances, Doxepin elixir (Sinequan) can be started at a low dose (one drop, or 0.67 mg) and slowly titrated upward. Fluoxetine, an SSRI, can be started at doses in the lower range and should generally be taken in the morning. The use of cyclobenzaprine (Flexeril) is supported by evidence primarily from one randomized controlled trial that followed 120 patients. Clinically, its use has many adherents. There is a note of caution when using antidepressants to manage Fibromyalgia: a significant portion of patients may find that their symptoms worsen while using these drugs. Symptoms must be monitored carefully as therapeutic blood levels are reached. Exercise. Aerobic and strength-training activities have been associated with significant improvements in pain, tender point counts and disturbed sleep in patients with FMS. Unfortunately, maintenance of exercise regimens tends to be poor in patients with FMS. Strategies for improving compliance, such as having the patient work out with a companion, can be discussed with the patient. Acupuncture. A substantial meta-analysis of studies using acupuncture in the treatment of Fibromyalgia confirms the empiric finding of medical acupuncturists that acupuncture is an extremely useful adjunctive treatment for many patients with Fibromyalgia. While not curative, acupuncture can enhance the patient's quality of life. The frequency of acupuncture is individualized and may range from weekly visits to visits once every 10 to 12 weeks. Information about physician acupuncturists practicing in a particular area may be obtained by contacting the American Association of Medical Acupuncture, 5820 Wilshire Blvd., Ste. 500, Los Angeles, CA 90036. This information is also on their Web site at http://www.medicalacupuncture.org. Chronic Opioid Analgesic Therapy (COAT) This intervention should be reserved for patients with moderate to severe pain or significant functional impairment and for those in whom other therapies are ineffective or contraindicated. Controlled clinical trials demonstrate COAT to be safe and effective in patients with pain that is not related to cancer. Patients requiring intermittent relief from pain may be given appropriate dosages of oral narcotic analgesics combined with acetaminophen. Those patients needing ongoing pain relief may be prescribed controlled-release oxycodone (Roxicodone) or morphine sulfate (Duramorph). Patients receiving COAT should be informed of the possibility of dependence and should be monitored regularly. Nonsteroidal Anti-Inflammatory Agents (NSAIDs). Although commonly prescribed in analgesic doses, NSAIDs have not been proved to be effective in the treatment of Fibromyalgia. Behavior Therapies Patients with Fibromyalgia may experience difficulty fulfilling work and social obligations because of poor symptom control. This difficulty can lead to social isolation and feelings of decreased self-efficacy. Collaborative care between family physicians and other health care professionals may provide optimal benefit for patients. Pain perception is an extremely complex phenomenon that may be modified by experience. Several behavior science approaches appear to hold benefit for Fibromyalgia. Cognitive Behavior Training A program of 20 hours of relaxation response training and movement therapy found to be effective in treating patients with low back pain included 28 patients with Fibromyalgia. Patients who completed the program reported reduced pain and other symptoms, as well as improved function and general health. One study reviewed two types of "formal self-management strategies" published from 1981 through 1996. The results tend to favor training in coping skills as being more effective than physical fitness training, but preliminary evidence suggests that combining both types of training may be more effective than either alone. As with all of the approaches to Fibromyalgia, this article points out that "not all individuals show the same response to these programs." A program combining cognitive behavior strategies, physical exercise, relaxation and information about chronic pain At the end of treatment and four months later, members of the study group reported less impairment in their daily lives. Hypnosis In a controlled study of 40 patients, hypnosis improved functioning and reduced pain more than physical therapy. Other Therapies Several therapies that are less well studied and less commonly used may be helpful in certain cases. Growth Hormone Therapy Treatment with recombinant growth hormone was highly effective in reducing symptoms and improving quality of life in a small, randomized study involving a subset of patients with Fibromyalgia and low insulin-like growth factor I levels. No significant side effects were encountered. Unfortunately, the cost of growth hormone is prohibitive for most patients. Chiropractic Treatment. Following four weeks of treatment, 21 patients with Fibromyalgia improved compared with control subjects receiving medication only. Support Groups and Online Chat Rooms. Many patients benefit from discussing their day-to-day lives with others who are also affected by Fibromyalgia. Support groups may be located through a local chapter of the Arthritis Foundation (AF). The AF address is 1330 W. Peachtree St., Atlanta, GA 30309. The goals of treatment for Fibromyalgia are to control pain and improve function. These goals can be met using a variety of techniques. A reasonable and cost-effective strategy may be initiated using antidepressants and exercise. If patients do not tolerate these measures or if additional symptomatic relief is needed to maintain function, the addition of hypnosis, behavior therapy, acupuncture and/or chiropractic treatment could then be considered. If pain control or function, or both, are still poor, COAT should then be considered. Members of various family practice departments develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee. Guest editors of the series are Linda N. Meurer, M.D., M.P.H., and Douglas Bower, M.D. NEXT PAGE - STATION HEALING- THE START OF ANOTHER JOURNEY Please visit the message boards and post a message See Photo's of members Please Sign Our Guest Book Healing Station Newsletter