Fibromyalgia

DIAGNOSIS

Your doctor will do a complete medical history and conduct a physical examination to learn about your symptoms, and to rule out other disorders that could also explain your problems. Your doctor will press on 18 points on your body. There are 18 “tender points” on your body that your doctor will press to test for pain. If you have fibromyalgia, you will feel pain when then doctor presses on at least 11 of these 18 points. If you don't have pain in these 18 specific spots, however, you still could have fibromyalgia.

There is no laboratory test for fibromyalgia. If you have severe and persistent fatigue, however, your doctor may order serum thyroxine and thyroid-stimulating hormone tests to rule out the possibility that thyroid abnormalities are causing your symptoms. Other routine screening tests might include a complete blood count, an erythrocyte sedimentation rate, and a chemical profile.

BASICS
Fibromyalgia is a condition characterized by chronic, widespread musculoskeletal pain and tenderness, restless sleep, and fatigue. Fibromyalgia is caused by a generalized disturbance in pain processing that leads to pain in muscles and soft tissue. Fibromyalgia is common, and occurs in about 3.4% of women and 0.5 % of men. Fibromyalgia occurs in all types of climates, nearly all countries, and in most ethnic groups.

Fibromyalgia is a physical condition, not a psychiatric illness. Fibromyalgia has only recently been recognized as a distinct physical condition. However, fibromyalgia patients with chronic symptoms may have psychological problems. In one study, 30% to 40% of people with fibromyalgia and its related conditions were found to suffer from depression, anxiety, or stress.

While painful, fibromyalgia is not a form of arthritis, and therefore does not actually damage joints or other bodily tissue. With proper treatment, many patients can experience substantial relief. While there is no known cure for fibromyalgia, it is possible to keep your symptoms under control. The best way to treat fibromyalgia is with a combination of medication, self-care, and alternative treatment. It is usually not necessary to stop working, although you should be careful not to get too stressed or overtired.

CAUSES
There is no known cause for fibromyalgia. However, people who suffer from fibromyalgia tend to share certain nervous system abnormalities that amplify and spread pain, and intensify other sensations. However, because many patients with fibromyalgia have disrupted sleep, there is thought to be a link between the condition and sleep disorders. Other factors that have been
found to contribute to the condition are stress, chemical imbalances in the brain and spinal cord (such as improper levels or the brain chemical serotonin), and abnormalities in the immune or endocrine systems. Fibromyalgia may have a genetic link.

SYMPTOMS
Widespread pain and stiffness are the most common symptoms of fibromyalgia. If you have fibromyalgia, you will most likely feel pain in all four limbs, your spine, and chest wall. Other common symptoms are poor sleep, fatigue, swelling in the soft tissue (especially the hands), numbness in the extremities, headaches, restless leg syndrome, and irritable bowel symptoms. Joints may be tender to the touch, and pain may limit range of motion. Other symptoms include jaw pain, memory impairment, menstrual cramping, dizziness, sensitive skin, and chemical sensitivities. It has become clear that considerable overlap exists between fibromyalgia and chronic fatigue syndrome, migraine headaches, irritable bowel syndrome, tempromandibular joint syndrome, and mitral valve prolapse syndrome.

Most people with this condition complain of aching and stiffness around the neck, shoulders, upper and lower back, and hip. Tenderness on compression in 11 out of 18 specific sites called "tender points" is the hallmark of fibromyalgia. People suffering with fibromyalgia may also experience tingling or numbness in the extremities, or tension headaches. They may have no underlying disorders, or may have such conditions as rheumatoid arthritis, Lyme disease, spinal arthritis, or irritable bowel syndrome.

Eighteen tender points in fibromyalgia
There are 18 "tender points" on your body that your doctor will press to test for pain. If you have fibromyalgia, you will feel pain when then doctor presses on at least 11 of these 18 points.

Symptoms of Fibromyalgia

• Widespread pain

• Stiffness

• Poor sleep

• Fatigue

• Swelling in soft tissue (especially hands)

• Numbness in the extremities

• Headaches

• Restless leg syndrome

• Diarrhea

• Abdominal pain

• Tender joints

• Limited range of motion

• Jaw pain

• Memory impairment

• Menstrual cramping

• Dizziness

• Skin and chemical sensitivities

Symptoms of Fibromyalgia

RISK FACTORS
Fibromyalgia is much more likely to affect women. The overwhelming majority of people with this condition (85%-90%) are women between the ages of 40 and 60.
Trauma, physical exertion, overuse, humid or cold weather, stress, and poor sleep may aggravate symptoms.

DIAGNOSIS
Your doctor will do a complete medical history and conduct a physical examination to learn about your symptoms, and to rule out other disorders that could also explain your problems.
Your doctor will press on 18 points on your body. There are 18 "tender points" on your body that your doctor will press to test for pain. If you have fibromyalgia, you will feel pain when then doctor presses on at least 11 of these 18 points. If you don't have pain in these 18 specific spots, however, you still could have fibromyalgia.
There is no laboratory test for fibromyalgia. If you have severe and persistent fatigue, however, your doctor may order serum thyroxine and thyroid-stimulating hormone tests to rule out the possibility that thyroid abnormalities are causing your symptoms. Other routine screening tests might include a complete blood count, an erythrocyte sedimentation rate, and a chemical profile.

SELF CARE
Get aerobic exercise three times a week to improve aerobic conditioning and overall pain. Brisk walking and swimming are the best types of exercise for many fibromyalgia patients. If you have significant pain or fatigue, begin slowly, exercising for just a few minutes. Then, gradually increase your time. Regular stretching and range-of-motion exercises keep muscle tissue and joints healthy, and can decrease pain.

Gentle stretching can help to ease pain and increase flexibility. Stretching helps you to avoid muscle tension and spasms. You can stretch on your own at home, or may ask a physical therapist for help. Some people with fibromyalgia find the “spray and stretch” technique to be helpful. For this method, you apply a prescription spray coolant to sore muscles to deaden the pain while you stretch. Tools such as a flexible “theraband” or a Swiss ball may make stretching easier.

Avoid caffeine and keep a regular sleep schedule. Taking hot baths or applying heating pads to tender areas may help ease pain.

DRUG THERAPY
Your doctor is the best source of information on the drug treatment choices available to you.

OTHER THERAPIES
Psychological counseling or cognitive-behavioral treatment may be beneficial. Cognitive- behavioral therapy can help relieve the intensity of your pain, reduce your number of tender points, lower your emotional distress, and increase your sense of control over pain.
Various types of cognitive-behavioral therapy have been studied, including activity pacing and patient and family education.

Occupational and physical therapy may be helpful. If repetitive job-related movements or the activities of daily living add to your pain, therapists can help by making adaptations and improvements.

ALTERNATIVE MEDICINE
Biofeedback may be a beneficial treatment. Studies have shown that people who received biofeedback treatments had fewer tender points, and lower pain intensity and morning stiffness. Biofeedback treatments consist of devices that measure your response to stress, and respond with either a flash of light or a beep. The response teaches you to recognize your own physical reaction to stress and to change your behavior to help you relax. Eventually people who have had
biofeedback can recognize their own physical reactions to stress without the feedback, and can modify their behavior accordingly.

Relaxation techniques help to manage stress. Fibromyalgia symptoms are made worse by stress, and, in an ongoing cycle, the pain of the condition stresses the body. Relaxation techniques can help. Some that have proven successful are meditation, breathing exercises, progressive relaxation, guided imagery, and autogenic training. Many classes, books, and audiotapes are available to help you learn these techniques.

Acupuncture may help to relieve pain. Several studies have shown acupuncture to be effective for reducing pain in people with fibromyalgia. The National Institutes of Health concluded that acupuncture could be useful as an additional treatment, as an alternative, or as part of a comprehensive management program for fibromyalgia.

Gentle massage may help to relieve muscular pain. Massage is helpful for increasing circulation of blood to tense, sore muscles. It may be used in conjunction with ultrasound or with the application of heat or cold. Massage is also helpful for removing built-up toxins such as lactic acid, and to help re-educate muscles and joints that have become misaligned.

If you want to try herbal sleep agents such as valerian root or melatonin, use them with caution. The Food and Drug Administration does not regulate herbal remedies, and there is little good information about how they interact with other drugs and their side effects. If you do try them, be sure to let your doctor know.

PROGNOSIS
Fibromyalgia cannot yet be cured, but its symptoms can be controlled. Although symptoms wax and wane over time, studies have shown that fibromyalgia rarely seems to disappear altogether. However, life expectancy is normal, and most patients can expect to lead a relatively normal life with appropriate management. The best course to achieve significant improvement is to implement a multidisciplinary approach, incorporating medication and nonpharmacologic approaches such as self-care.

FOLLOW-UP
Treatment of this condition must be individualized. It is helpful to learn to anticipate painful flare-ups, and to manage them before they become overwhelming. During flare-ups, it is most important to focus on sleeping well, decreasing stress and anxiety, and possibly altering medications. Learn what strategies work best for you and employ them right away. Local tender- point injections and application of heat may help. You may also benefit from attending an ongoing patient support group; they are available in many communities.

Rheumatology

Rheumatic diseases consist of more than 100 conditions, including all forms of arthritis (e.g., rheumatoid arthritis and osteoarthritis), certain autoimmune diseases (e.g., systemic lupus), musculoskeletal pain disorders and osteoporosis. Rheumatic diseases can affect virtually any part of the body. They are usually associated with inflammation (swelling and redness), almost always accompanied by pain and have symptoms that can have a profound effect on the ability to perform daily activities.

Rheumatic diseases can be particularly challenging for patients who have them. Besides affecting the physical body, energy levels and the ability to perform daily activities, these conditions can also affect emotional health.

Rheumatic conditions are different from other diseases, while many diseases can be cured; rheumatic diseases require an ongoing process of adaptation to maximize each patient's ability to function and well being over a long period of time.

Knowledge of the causes of rheumatic diseases and their impact on the body, as well as new approaches to treatment of these conditions, is expanding rapidly. The following information are provided to help patients manage the condition most effectively.


How Rheumatic Diseases Affect Your Life
The chronic pain, recurring flare-ups and disabling effects on joints and the ability to cope with the demands of daily living can take an emotional toll, as well as a physical one. This toll may take the form of depression or emotional distress, stress or impact on relationships with family and friends. It may involve changes to career plans, roles and relationships with other people. Therapists or behavior psychologists may be able to help you put things in perspective. They can also help you develop coping skills, including relaxation techniques.

More than 30 years of research has shown that a patient's beliefs about illness, ability to cope with the challenges of rheumatic disease, confidence in coping abilities and support system all have an impact on health. The good news is that attitudes, coping skills and confidence can be learned to enhance physical and emotional health. The ability to cope with pain and attitude about coping ability are influenced by:

• Level of independence and reliance on others

• Resourcefulness in solving challenges

• Knowledge of the specific condition

• Coping skills

• How family, friends or support groups respond to difficulties

The medical, emotional and behavioral aspects of a rheumatic disease are linked. Adjustments in each area will be unique and individual. Over the course of the disease, the elements that cause or maintain certain feelings, quality of health and behavior in response to the disease will vary. Any approach that developed by the patient and doctor to manage the condition should be broad enough to cover a range of issues that affect both physical condition and emotional and psychological responses.

Chronic Pain
Ongoing pain that gets worse from time to time is a primary source of emotional distress for persons with rheumatic diseases. One study based on data from the National Institutes of Health found that over the span of their lifetimes, more than 60 percent of those with arthritis became depressed or developed a psychological or emotional disorder. This rate is higher than that found in person with cancer, diabetes or stroke.

The more pain a person has, the more likely he or she is of having depression. For many people a feeling of being powerless to do anything about the pain - or feeling that the pain will never end - makes depression or mood disturbance even more likely

Strategies for Emotional Health
Despite the challenges that a rheumatic disease presents, much can be done to improve physical and emotional health, such as to:

• Become a partner with the doctor in managing the condition. Be sure to communicate with him or her.

• Develop a more positive attitude towards the disease and symptoms and the challenges they create

• Learn about the disease and ways of managing it

• Learn about treatment and management approaches, such as drugs or complementary medical approaches

• Manage life through good nutrition, proper exercise, getting enough rest, etc. to maintain the best health possible

• Enhance problem-solving and coping skills

• Develop role models and support group contacts to share coping strategies with

• Set goals and get feedback from others about progress and successes

Anything that makes patients feel more powerful, more in control and better able to manage the condition will be helpful. Patients should not forget to enlist the assistance of family, spouses or others who are important in their lives. The more they know about the condition and managing it, the more support they can offer.

Approaches to Managing Depression
A number of approaches can be used to manage the depression or emotional distress associated with chronic pain or a rheumatic condition. These include:

• Reducing stress related to the disease or its treatment or to environmental demands

• Managing your lifestyle to avoid stress, fatigue or activities that strain the joints or increase pain

• Managing your thought processes to reduce negative thinking and to give you better control. Called cognitive behavioral therapy, it also includes using imagery or distraction to create a more positive and powerful attitude toward your condition and your ability to manage it.

• Scheduling pleasant events to put you in a better mood, reward positive behaviors and reduce depression

• Learning problem-solving skills

Naga--My Favorite Painkiller

TASTELESS, colorless, odorless and painful, pure capsaicin is a curious substance. It does no lasting damage, but the body’s natural response to even a modest dose (such as that found in a chili pepper) is self-defense: sweat pours, the pulse quickens, the tongue flinches, tears may roll. But then something else kicks in: pain relief. The bloodstream floods with endorphins—the closest thing to morphine that the body produces. The result is a high. And the more capsaicin you ingest, the bigger and better it gets.

Which is why the diet in the rich world is heating up. Hot chilies, once the preserve of aficionados with exotic tastes for cuisine from places such as India, Thailand or Mexico, are now a staple ingredient in everything from ready meals to cocktails.

Naga: Inhaling its vapor makes your nose tingle. Touching it is painful; cooks are advised to wear gloves before handling it. By the standards of other chilies, it is astronomically hot. On the commonly used Scoville scale (based on dilution in sugar syrup to the point that the capsaicin becomes no longer noticeable to the taster) it rates 1.6m units, close to the 2m score of pepper spray used in riot control.

The pepper that previously counted as the world’s hottest, the Bhut Jolokia grown by the Chile Pepper Institute at the New Mexico State University, scored just over 1m. That in turn displaced a chili grown by the Indian Defense Research Laboratory in Tezpur, which scored a mere 855,000. The hottest habanero chilies score a wimpy 577,000.

Adrenalin plus natural opiates form an unbeatable combination
The reason may be that capsaicin excites the trigeminal nerve, increasing the body’s receptiveness to the flavor of other foods. Indeed, capsaicin has useful medical effects. By disabling a part of the nervous system called “transient receptor potential vanilloid 1” it can stop the body registering the pain caused by rheumatoid arthritis, for example. It can also be used to help patients with multiple sclerosis, amputees, and people undergoing chemotherapy.

With rather less scientific evidence, a capsaicin product is marketed as an alternative to Botox, a wrinkle-smoothing cosmetic treatment. But does it do any harm? The use of pepper spray as a weapon, and chili powder as a means of torture, suggests that it must. Certainly capsaicin can be painful, causing stress: in itself a potential health risk. A big dose incapacitates. But as far as permanent physical damage is concerned, the evidence is negligible to non-existent.

That seems to contradict common sense, which suggests that hot food causes an upset stomach—or what medical specialists call “gastric mucosal injury”. A study in 1987 on the effects of ordinary pepper produced some signs of gastric exfoliation (stripping away the stomach lining) and some bleeding—though the effects were less than those produced by aspirin.

An alarming-sounding experiment a year later involved volunteers being fed minced jalapeño peppers through a tube, directly into the stomach. The results, observed by an endoscope (a camera on a tube) revealed no damage to the mucous membrane. Against that is a study of heavy chili-eaters in Mexico City, who appeared to have higher stomach cancer rates than a control group. But the rate of illness had no correlation with the frequency of chilies eaten, leading to speculation that other factors may be at work.


Humans are the only mammals to eat chilies. Other species apparently reckon that nasty tastes are a powerful evolutionary signal that something may be poisonous. A psychology professor at the University of Pennsylvania (one of the world’s best-known authorities on the effects of capsaicin) has had no success in persuading rats to eat chilies, and very limited success with dogs and chimpanzees: the handful of cases where these animals did eat chilies seemed to be because of their strong relationships with human handlers.


This offers a clue to the way in which mankind comes to develop a chili eating habit. In the same way as young people may come to like alcohol, tobacco and coffee (all of which initially taste nasty, but deliver a pleasurable chemical kick), chili-eating normally starts off as a social habit, bolstered by what's called “benign masochism”: doing something painful and seemingly dangerous, in the knowledge that it won’t do any permanent harm.

The adrenalin kick plus the natural opiates form an unbeatable combination for thrill-seekers. Just don’t get it in your eyes.

Fish Oil and Omega 3, 6 and 9; what’s the difference and who cares?

Most physicians agree on the many health benefits of fish oil in the diet.

The hype about this supplement reminds me of the days when my mother, believing in the health powers of fish oil, made me down a tablespoon of Cod liver oil and I gagged for the rest of the day because of the fish stink it left in my mouth. Well, maybe mom did know a thing or two about what was good for us. Or didn’t she?

Cod liver oil contains both vitamins D, A, and healthy omega-3 fats. These two vitamins are very important to people who cannot get regular sun exposure year round, yet recent research has discovered that the ratios of these two vitamins are of great importance in order to extract optimal health benefits but unfortunately Cod liver oil does not supply these vitamins in healthy ratios to one another. Therefore I recommend fish oil.

Omega -3 contains two of the most important fatty acids which are EPA and DHA. Both EPA and DHA are in limited supply and can only be found in oily fish and fish supplements. DHA is important for pregnant and nursing mothers and for young children for healthy development of the brain and vision and EPA is considered the most important for everyone else as it is necessary for the efficient functioning of the brain and the body on a cellular level. Omega-3 also has anti-inflammatory and anti-coagulant properties which are beneficial as they can reduce inflammation and can provide protection against cardiovascular disease, arthritis, skin conditions, depression, and other mood related disorders.

The body also constructs hormones from both omega-3 and 6 fatty acids. Omega-6 fatty acids are classified as the acids that tend to increase inflammation, which is an important part of the immune response; it also aids in blood clotting and cell proliferation. Some benefits of omega-6 are that it can help with bloating and pain related with PMS, maintains healthy skin, hair and, nails, and generally helps to bring about hormonal and emotional balance. Because omega-3 fatty acids aid in doing the opposite as omega-6 and decrease inflammation, it is important that both these families of hormones are balanced in order to maintain optimum health. The imbalance between these two fatty acids may contribute to obesity, depression, dyslexia, hyperactivity, and even a tendency towards violence. The dietary imbalance of these two fatty acids may explain the rise of such diseases as asthma, many forms of cancer, coronary heart disease, autoimmunity and neurodegenerative diseases, all of which are believed to stem from inflammation in the body.

Omega-9 is a monounsaturated fat which means is a semi-essential fatty acid. The body can produce this provided that there is enough omega-3 and omega-6 in the body. If a diet is low in omega-3 and 6, then the body cannot produce enough omega-9 and therefore making it an essential fatty acid which means more Omega-9 has to be added to the diet. Some of the benefits of omega-9 are that it lowers cholesterol levels, thereby reducing the risk of cardiovascular disease; reduces hardening of the arteries and insulin resistance, which improves blood sugar maintenance; it improves immune function, and provides protection against certain types of cancer.

Exact figures on dosing have yet to be established due to each person’s own determining factors such as age, health, physical structure, and severity of fat deficiency in the body. The American Heart Association recommends two servings of fish a week such as salmon, herring, lake trout, albacore tuna, and mackerel, in order to support cardiovascular health. In order to know if a person is getting the right dose of fish oil, it is recommended to take one soft gel capsule twice daily containing 1000mg of omega-3, 6, and 9.

Once again, as much as I hate to admit it, Mom was right!

About Dr. Kashow

After graduating from medical school in Germany, Dr. Iyad Kashow worked for three years with the Israeli Red Cross as a general Internist. He came to Evanston, Ill. to complete his residency at St. Francis Hospital of Evanston. During his third year of residency there, he served as Chief Resident.

After completing his residency, Dr. Kashow became the Associate Director of the residency program, a position he held for three years. Dr. Kashow has been in private practice for over 10 years.

His philosophy is treating diseases not only by prescribing medications, but by addressing nutrition, stress and lifestyle habits and incorporating necessary modifications to optimize disease management.

Realizing the positive effects of good nutrition and healthy weight on general well-being, he has prepared “Secrets of the Mediterranean Diet,” a guide on healthy eating.

Dr. Kashow has extensive training and experience in rheumatology. He spent over two years learning to diagnose and treat diseases of the joints and connective tissue such as rheumatoid arthritis, lupus and fibromyalgia.

He performs in-office procedures such as joint injections, when indicated, to assist his patients in achieving pain relief and optimal functioning.`

Dr. Kashow was certified by the American Board of Internal Medicine in 1993 and recertified in 2003. He is a member of the American College of Physicians and the American Medical Association. Dr. Kashow is on staff at Rush-Copley Hospital in Aurora and Condell Medical Center in Libertyville.