Anyone who has ever made and broken a New Year's Resolution can appreciate the difficulty of behavior change. Making a lasting change in behavior is rarely a simple process, and usually involves a substantial commitment of time, effort, and emotion.

Whether you want to lose weight, stop smoking, or accomplish another goal, there is no single solution that works for everyone. You may have to try several different techniques, often through a process of trial-and-error, in order to achieve your goal. It is during this period that many people become discouraged and give up on their behavior change goals. The key to maintaining your goals is to try new techniques and find ways to stay motivated.

Psychologists have developed a number of ways to effectively help people change their behavior. Many of these techniques are used by therapists, physicians, and teachers. Researchers have also proposed theories to explain how change occurs. One of these theories, known as the 'Stages of Change' model, has been used to help people understand the change process. This model demonstrates that change is rarely easy and often requires a gradual progression of small steps toward a larger goal.

The Elements of Change

In order to succeed, you need to understand the three most important elements in changing a behavior:

• Readiness to change - Do you have the resources and knowledge to successfully make a lasting change?


• Barriers to change - Is there anything preventing you from changing?


• Expect relapse - What might trigger a return to a former behavior?

One of the best-known approaches to change is known as the 'Stages of Change' model, which was introduced in the late 1970's by researchers James Prochaska and Carlo DiClemente who were studying ways to help people quit smoking. The Stages of Change Model has been found to be an effective aid in understanding how people go through a change in behavior. In this model, change occurs gradually and relapses are an inevitable part of the process of making a lifelong change. People are often unwilling or resistant to change during the early stages, but eventually develop a proactive and committed approach to changing a behavior.

Precontemplation Stage

The earliest stage of change is known as precontemplation. During the precontemplation stage, people are not considering a change. People in this stage are often described as "in denial" due to claims that their behavior is not a problem. If you are in this stage, you may feel resigned to your current state or believe that you have no control over your behavior. In some cases, people in this stage do not understand that their behavior is damaging or are under-informed about the consequences of their actions.

If you are in this stage, begin by asking yourself some questions. Have you ever tried to change this behavior in the past? How do you recognize that you have a problem? What would have to happen for you to consider your behavior a problem?

Contemplation Stage

During this stage, people become more and more aware of the potential benefits of making a change, but the costs tend to stand out even more. This conflict creates a strong sense of ambivalence about changing. Because of this uncertainty, the contemplation stage of change can last months or even years. In fact, many people never make it past the contemplation phase. During this stage, you may view change as a process of giving something up rather than a means of gaining emotional, mental, or physical benefits.

If you are contemplating a behavior change, there are some important questions to ask yourself: Why do you want to change? Is there anything preventing you from changing? What are some things that could help you make this change?

Preparation Stage

During this stage, you might begin making small changes to prepare for a larger life change. For example, if losing weight is your goal, you might switch to lower-fat foods. If your goal is to quit smoking, you might switch brands or smoke less each day. You might also take some sort of direct action such as consulting a therapist, joining a health club, or reading self-help books.

If you are in the preparation stage, there are some steps you can take to improve your chances of successfully making a lasting life change. Gather as much information as you can about ways to change your behavior. Prepare a list of motivating statements and write down your goals. Find outside resources such as support groups, counselors, or friends who can offer advice and encouragement.

Action Stage

During the fourth stage of change, people begin taking direct action in order to accomplish their goals. Oftentimes, resolutions fail because the previous steps have not been given enough thought or time. For example, many people make a New Year's Resolution to lose weight and immediately start a new exercise regimen, begin eating a healthier diet, and cut back on snacks. These definitive steps are vital to success, but these efforts are often abandoned in a matter of weeks because the previous steps have been overlooked.

If you are currently taking action towards achieving a goal, congratulate and reward yourself for any positive steps you take. Reinforcement and support are extremely important in helping maintain positive steps toward change. Take the time to periodically review your motivations, resources, and progress in order to refresh your commitment and belief in your abilities.

Maintenance Stage

The maintenance phase of the Stages of Change Model involves successfully avoiding former behaviors and keeping up new behaviors. During this stage, people become more assured that they will be able to continue their change.

If you are trying to maintain a new behavior, look for ways to avoid temptation. Try replacing old habits with more positive actions. Reward yourself when you are able to successfully avoid a relapse. If you do lapse, don't be too hard on yourself or give up. Instead, remind yourself that it was just a minor setback. As you will learn in the next stage, relapses are common and are a part of the process of making a lifelong change.

Relapse Stage

In any behavior change, relapses are a common occurrence. When you go through a relapse, you might experience feelings of failure, disappointment, and frustration. The key to success is to not let these setbacks undermine your self-confidence. If you lapse back to an old behavior, take a hard look at why it happened. What triggered the relapse? What can you do to avoid these triggers in the future?

While relapses can be difficult, the best solution is to start again with the preparation, action, or maintenance stages of behavior change. You might want to reassess your resources and techniques. Reaffirm your motivation, plan of action, and commitment to your goals. Also, make plans for how you will deal with any future temptations.

Resolutions fail when the proper preparation and actions are not taken. By approaching a goal with an understanding of how to best prepare, act, and maintain a new behavior, you will be more likely to succeed.

Introduction

There is an increasing interest in the role of psychological factors in fibromyalgia (FM), and studies have been published on associated psychological variables, psychopathological explanations, assessment instruments and psychological intervention programs. Various investigations have centered on the relationship of FM with pain, depression, anxiety and quality of life. The Copenhagen declaration in 1992 described psychological patterns frequently associated with FM, such as anxiety and depression, and there is a growing interest in this aspect among professionals of different fields. Nevertheless, many authors consider that psychological factors are more frequently the result than the cause of pain and disability in FM, and this issue remains controversial.

Some symptoms of FM are similar to those observed during depression, and antidepressants have been administered to FM patients to treat sleep disorders and pain symptoms. Review of the literature on the association between FM and depression reveals two divergent research lines. Hudson and others believe that a direct association cannot be established between FM and depression, whereas Gruber and others (1996) propose a common etiology for FM and depression. Significant differences in psychological state between patients with FM and depression were reported in a study on FM, pain intensity and duration and psychological alterations; the results of depression and anxiety questionnaires indicated that the somatic expression of depression differed between the two patient groups. The relationship between depression and FM remains controversial. Although antidepressants can reduce pain and fatigue in FM, the effects of these drugs vary in degree and duration among patients.

Methods

Patients with FM undergoing pharmaceutical therapy were recruited from among members of the Almeria Fibromyalgia Association with clinical records at the Torrecardenas Hospital Complex (Almeria, Spain). Inclusion criteria were: diagnosis of FM (by rheumatology specialist), age of 16–65 years and agreement to attend afternoon therapy sessions. Exclusion criteria were: presence of physical disease, psychological disease, infection, fever, hypotension or skin disorders or respiratory alterations that would limit the application of the treatments.

Out of the 376 patients in the accessible population, 351 were subjected to a randomization procedure to recruit a sample of 119 patients. Out of these 119 patients, 15 were excluded, and the remaining 104 were randomly assigned by means of a balanced stratified assignment to an intervention (n = 52) or placebo (n = 52) group. The groups were balanced for type of medication received, sex and age, using a stratification system that generates a sequence of letters (from a table of correlatively ordered permutations) for each category and combination of categories.

• 21 patients were treated with muscle relaxants
• 32 were treated with antidepressants
• 46 were treated with anxiolytics
• 59 were treated with anti-inflammatories
• 36 were treated with corticoids
• 84 were treated with analgesics

Intervention

The intervention group underwent a craniosacral therapy protocol, with two weekly sessions of 1 hour for 25 weeks. The treatment was carried out by an expert craniosacral therapist with the patient in prone position. This therapy consists of applying very mild manual traction on cranial bones in flexion or extension stages of the craniosacral cycle. The aims were to contribute to re-establishing the normal movement of cranial bones and to intervene in the autonomic nervous system by releasing bone and membranous restrictions. Craniosacral therapy procedures were:

• still point (occipital)
• compression-decompression of temporomandibular joint
• decompression of temporal fascia
• compression-decompression of sphenobasilar joint
• parietal lift, frontal lift, scapular waist release and pelvic diaphragm release

The placebo group underwent two weekly 30-min sessions of sham ultrasound treatment in which the disconnected probe (4 cm in diameter) was applied to the cervical area (10 min), lumbar region (10 min) and both sides of the knees (10 min). The sham treatment was performed with the patient in prone position. The screen of the ultrasound was covered to ensure that the patient was unaware that the equipment was disconnected. Both patient groups were instructed not to change their pharmacological treatment during the 25-week study period.

Results

During the study, 9 patients withdrew from the intervention group and 11 from the placebo group. Reasons for withdrawal were death of spouse, start of another type of treatment, change in pharmacologic therapy during treatment period, and missing sessions due to acute pain crisis and forgetfulness. The final study sample comprised 84 patients (81 females) aged 34–63 years with a mean age of 49.08 ± 14.17 years. There were no differences in baseline demographic characteristics between the intervention group and placebo group. The groups did not differ significantly in state anxiety, trait anxiety or VAS scores but differed in all dimensions of the SF-36 questionnaire with the exception of vitality. In the whole study population, there were significant correlations at baseline between age and physical role, vitality and general health, habitual sleep efficiency and social function and between mental health and emotional role, sleep duration and habitual sleep efficiency.

At 35 Weeks After Intervention

At 35 weeks, the intervention group showed significant improvements in state anxiety and trait anxiety versus baseline scores. No changes were observed in the placebo group. The groups differed significantly in trait anxiety. Depression scores did not differ significantly between groups or with respect to baseline values.

VAS-measured pain improved significantly in the intervention group versus baseline and differed between groups. The intervention group also showed significant improvement in physical function, physical role, body pain, general health, vitality and social function. The placebo group showed no significant changes versus baseline in SF-36 questionnaire dimensions. The groups differed in physical function, physical role, body pain, general health, vitality and social function. The intervention group showed a significant overall improvement in Pittsburgh sleep quality index score, and the groups differed significantly in the sleep duration and sleep disturbance items.

Six Months Post-intervention

No significant intra-group or inter-group differences were found in state anxiety, depression or pain with respect to baseline. The intervention group showed a significant improvement (versus baseline) in physical function. The placebo group showed no differences (versus baseline) in any SF-36 questionnaire item. The groups differed significantly in physical function and vitality. The groups also differed significantly in sleep duration, habitual sleep efficiency and sleep disturbance.

1 Year Post-intervention

At 1 year, the intervention group showed a significant improvement (versus baseline) in sleep duration, habitual sleep efficiency and daily dysfunction. No significant differences in anxiety, depression, pain or quality of life were found between groups or with respect to baseline values. In the intervention group, trait anxiety was correlated with Beck depression score.

Conclusions

The present study shows that craniosacral therapy improves the quality of life of patients with fibromyalgia, reducing their perception of pain and fatigue and improving their night rest and mood, with an increase in physical function. Our craniosacral therapy protocol also reduces anxiety levels, partially improving the depressive state. This manual therapy modality must be considered as a complementary therapy within a multidisciplinary approach to these patients, also including pharmaceutical, physiotherapeutic, psychological and social treatments.

In April I did an article on Medications Used to Treat Fibromyalgia. We thought it might be helpful for you to learn more about these medications. This month I will take an in-depth look at Tramadol.

Tramadol is a narcotic-like pain reliever. Tramadol is used to treat moderate to severe pain. Tramadol extended-release is used to treat moderate to severe chronic pain when treatment is needed around the clock.

Before Using This Medicine

You should not take tramadol if you have ever been addicted to drugs or alcohol.

Take tramadol exactly as it was prescribed for you. Do not take it in larger doses or for longer than recommended by your doctor. Do not take more than 300 milligrams of tramadol in one day.

Do not stop using this medication suddenly without talking to your doctor. You may need to gradually reduce the dose. Withdrawal symptoms may occur when you stop using tramadol. Withdrawal symptoms include:

• anxiety
• sweating
• nausea
• diarrhea
• tremors
• chills
• hallucinations
• trouble sleeping
• breathing problems

Call your doctor at once if you have any of these withdrawal symptoms after you stop using tramadol.

Do not crush the tramadol tablet. This medicine is for oral (by mouth) use only. Powder from a crushed tablet should not be inhaled or diluted with liquid and injected into the body. Using this medicine by inhilation or injection can cause life-threatening side effects, overdose, or DEATH.

Seizures (convulsions) have occurred in some people taking tramadol. You may be more likely to have a seizure while taking tramadol if you have a history of seizures or head injury, a metabolic disorder, or if you are taking certain medicines such as antidepressants, muscle relaxers, or medicine for nausea and vomiting.

Seek emergency medical attention if you think you have used too much of this medicine. A tramadol overdose can be FATAL. Symptoms of a tramadol overdose may include:

• drowsiness
• shallow breathing
• slow heartbeat
• extreme weakness
• cold or clammy skin
• feeling light-headed
• fainting
• coma

While you are taking tramadol, do not drink alcohol or use drugs that make you sleepy such as:

• cold medicine
• other pain medications
• muscle relaxants
• medicine for seizures, depression or anxiety

These drugs may slow your breathing or increase drowsiness when used together with tramadol. Tramadol can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

How To Use This Medicine

Take tramadol exactly as it was prescribed for you. Do not take it in larger doses or for longer than recommended by your doctor. Follow the directions on your prescription label. Do not take more than 300 milligrams of tramadol in one day.

Take each dose with a full glass of water. Tramadol can be taken with or without food, but take it the same way each time.

Do not crush the tramadol tablet. This medicine is for oral (by mouth) use only. Powder from a crushed tablet should not be inhaled or diluted with liquid and injected into the body. Using this medicine by inhilation or injection can cause life-threatening side effects, overdose, or death.

Do not crush, chew, or break an extended-release tablet. Swallow the pill whole. It is specially made to release medicine slowly in the body. Breaking the pill would cause too much of the drug to be released at one time.

If you use the tramadol extended-release tablet, the tablet shell may pass into your stools (bowel movements). This is normal and does not mean that you are not receiving enough of the medicine.

Tramadol may be habit-forming. Tell your doctor if you feel the medicine is not working as well in relieving your pain. Do not change your dose without talking to your doctor.

Do not stop using this medication suddenly without talking to your doctor. You may need to gradually reduce the dose. Withdrawal symptoms may occur when you stop using tramadol. Withdrawal symptoms include:

• anxiety
• sweating
• nausea
• diarrhea
• tremors
• chills
• hallucinations
• trouble sleeping
• breathing problems

Call your doctor at once if you have any of these withdrawal symptoms after you stop using tramadol. Store tramadol at room temperature away from moisture and heat.

Precautions While on this Medicine

You should not take tramadol if you have ever been addicted to drugs or alcohol. Do not take tramadol if you are intoxicated (drunk), or if you have recently used any of the following drugs:

• alcohol
• narcotic pain medicine
• sedatives or tranquilizers (such as Valium®)
• medicine for depression or anxiety
• medicine for mental illness (such as bipolar disorder, schizophrenia)
• street drugs

' Seizures have occurred in some people taking tramadol. Your risk of a seizure may be higher if you have any of these conditions:

• history of drug or alcohol addiction
• history of epilepsy or other seizure disorder
• history of head injury
• metabolic disorder

Talk with your doctor about your individual risk of having a seizure from this medicine. Before taking tramadol, tell your doctor if you are allergic to any drugs, or if you have:

• kidney disease
• liver disease
• stomach disorder
• history of depression, mental illness, or suicide attempt

If you have any of these conditions, you may not be able to use tramadol, or you may need a dosage adjustment or special tests during treatment.

This medication may be harmful to an unborn baby. Tramadol may also cause SERIOUS or FATAL side effects in a NEWBORN if the mother uses the medication during pregnancy or labor. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Tramadol can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

Older adults may be more sensitive to the effects of tramadol. If you are over 65, your doctor may Tramadol should not be given to a child younger than 16 years of age.

Overdosage

Seek emergency medical attention if you think you have used too much of this medicine. A tramadol overdose can be FATAL. Symptoms of a tramadol overdose may include:

• drowsiness
• shallow breathing
• slow heartbeat
• extreme weakness
• cold or clammy skin
• feeling light-headed
• fainting
• coma

Side Effects

Get emergency medical help if you have any of these signs of an allergic reaction:

• skin rash or hives
• difficulty breathing
• swelling of your face, lips, tongue, or throat

Call your doctor at once if you have any of these SERIOUS side effects:

• seizure (convulsions)
• red, blistering, peeling skin rash
• shallow breathing, weak pulse

Continue taking tramadol and talk to your doctor if you have any of these LESS serious side effects:

• dizziness
• drowsiness
• weakness
• nausea
• vomiting
• constipation
• loss of appetite
• blurred vision
• flushing (redness, warmth, or tingly feeling)
• sleep problems (insomnia)

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

Drug Interactions

You may be more likely to have a seizure (convulsions) if you take tramadol while you are using certain other medicines. Do not take tramadol without telling your doctor if you also use any of the following:

• isocarboxazid (Marplan®)
• tranylcypromine (Parnate®)
• phenelzine (Nardil®)
• selegiline (Eldepryl®, Emsam®)
• amitriptyline (Elavil®)
• citalopram (Celexa®)
• clomipramine (Anafranil®)
• desipramine (Norpramin®)
• escitalopram (Lexapro®)
• fluoxetine (Prozac®, Sarafem®)
• fluvoxamine (Luvox®)
• imipramine (Tofranil®)
• nortriptyline (Pamelor®)
• paroxetine (Paxil®)
• sertraline (Zoloft®)

Before taking tramadol, tell your doctor if you also use:

• carbamazepine (Tegretol®)
• warfarin (Coumadin®)
• digoxin (Lanoxin®, Lanoxicaps®)
• ketoconazole (Nizoral®)
• erythromycin (E-Mycin®, E.E.S.®, Ery-Tab®)
• rifampin (Rifadin®, Rimactane®, Rifater®)
• St. John's wort
• quinidine (Quinaglute®, Quinadex®, Cardioquin®, Quinora®)
• cold medicine
• pain medications
• muscle relaxants
• medicine for seizures, depression or anxiety

If you are using any of these drugs, you may not be able to use tramadol or you may need dosage adjustments or special tests during treatment.

There may be other drugs not listed that can affect tramadol. 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.

I hope this article has been helpful. Next month the focus will be on Ambien.

Before you go to that first alternative medicine appointment, ask your insurance company the big question: Will you pay for this? In many ways, a practitioner of alternative medicine follows the same steps for treatment that a conventional medical doctor uses. But because alternative medicine is still considered outside the scope of traditional health care, many insurance companies do not cover these visits or offer limited coverage. It's a good idea to have a handle on the financial aspect of alternative medicine before making an appointment.

Does Insurance Cover It?

The majority of alternative medicine treatments are still being paid for out-of-pocket. Though consumer demand is causing more insurance companies to reconsider their policies on these therapies, this coverage remains limited across the board.

The more common types of alternative medicine that are recognized by insurance companies include:

• Acupuncture
• Chiropractic
• Massage
• Naturopathy
• Biofeedback

What Should I Ask My Insurance Company?

The best thing to do is to call your insurance company and ask whether it provides coverage for the treatment you're seeking.

If you find out that your insurance company does cover the treatment, there are still some additional questions to ask:

• How can I get this treatment? Does the treatment need to be ordered by a prescription or through a referral from a primary care provider?


• What practitioners can I see? Am I free to see any practitioner I want, or do I have to see someone within the insurance company's network? Some insurance companies have a network of alternative medicine practitioners to whom their coverage is limited, while others offer at least partial coverage for alternative medicine offered by out-of-network providers.


• How many visits am I entitled to? Some insurance companies have a dollar amount as to the limit while others specify the number of visits.


• Do I have to meet a deductible before my coverage kicks in? Deductibles for alternative medicine can sometimes be higher than for traditional medical visits, so ask this question even if you know what your deductible normally is.

Since many insurance companies are still in the early stages of covering alternative medicine, it's wise to keep records of calls with company representatives, in addition to saving whatever bills or other written correspondence you may receive. These items will come in handy if a claim dispute surfaces at a later time.

How Much Will It Cost Me?

Once you're fully informed about your insurance coverage for alternative medicine, it's time to contact your alternative medicine practitioner to find out how much it will cost you. The practitioner should be able to answer the following important questions:

• How much does the initial appointment cost and how much are follow-ups? It is not uncommon for alternative medicine practitioners to charge more for initial appointments.


• How many visits will I need? The practitioner probably won't be able to give you an exact number without seeing you in person, but he or she should be able to estimate based on past experience treating patients with similar conditions.


• Should I expect any costs besides the visit fee? Sometimes alternative medicine practitioners charge extra for tests, equipment, dietary supplements, and herbs.

Patients who don't have insurance coverage for alternative medicine should ask the practitioner whether they could work together to develop a long-term payment plan. Also, some practitioners offer sliding-scale fees, which allow people to pay whatever they think they can afford based on their incomes.

Pulmonary hypertension is a life-changing diagnosis, but these two women manage not only to cope with this condition but to live normal lives. Annette Markin was used to doing it all: caring for her family, teaching first grade, tending to their dogs and horses, mowing the lawn, and even driving a tractor on her family's Omaha acreage.

But that began changing about six years ago, when Markin started feeling tired and out of breath. She visited several doctors, who ran tests but could find nothing wrong. "I was in my late forties, I was chubby - we all assumed I was just overweight, out of shape, and getting older," says Markin, who is now 53. It wasn't until June 2005 that she got the official diagnosis: pulmonary hypertension. She was given a life expectancy of three to five years.

The diagnosis changed Markin's life considerably. Her doctor immediately placed her on Flolan (epoprostenol), a drug that has controlled symptoms and improved survival and quality of life for many people with pulmonary hypertension. Unfortunately, these benefits come at a price: The drug must be administered continuously through a catheter in a vein leading directly into the heart, and the medication must be kept cold.

Markin now wears a special pack around her waist that contains a canister of Flolan in ice, with a tube that transports the drug from its canister to a catheter implanted in her chest. When the canister runs dry (most canisters last for up to 24 hours), she has only five to seven minutes to insert a new one before her symptoms return, with possibly fatal consequences. She also requires supplemental oxygen to help her breathe more easily.

At first, Markin tried to stay on her old routine as much as possible, especially when it came to her job.

"I had been teaching for 27 years - it was something I loved," she says. Staying late, coming in early, and working on weekends were not chores but pleasures for her. After her diagnosis, Markin told her principal and school nurse about her condition and taught them how to manage her Flolan apparatus, just in case. That foresight paid off in March 2006, when the pump that transported the drug to her catheter failed in the middle of a class.

"It happened about a half hour before the end of the day, and at first I thought I could just wait until school was out and take care of it then," she says. But, with only five to seven minutes before the drug levels in her blood would drop too low, she realized she couldn't afford to take that risk. She had to stop the class, alert the nurse and the principal, find another teacher to watch her students, and hastily restart the pump. "I realized then I couldn't keep teaching," she says ruefully. These days, she can't even be a substitute teacher. "Even reading to the kids wears me out."

A Career Cut Short by Pulmonary Hypertension

Atlanta resident Brittany Evans likewise had to give up a career she loved due to pulmonary hypertension. About four years ago, at the age of 22, Evans was putting in 70-hour weeks as a pastry chef when she started feeling breathless and unusually tired. Over the next 11 months, she visited an allergist and five other doctors, all of whom gave her different diagnoses, including the old standby, "It's all in your head." By then, she says, "I was so sick I could hardly speak without stopping to catch my breath."

Finally, one of her doctors ordered a stress echocardiogram, which involves gathering ultrasound images of the heart before and after a six-minute walk on a treadmill. But Evans never made it to the six-minute mark. "I passed out and turned blue 3 minutes in," she says.

Like Markin, Evans has the idiopathic form of pulmonary hypertension, in which doctors cannot identify a specific cause. And like Markin, she was placed on Flolan, which immediately improved her breathing. "I didn't realize how sick I was until I could breathe again," she says. However, Evans only remained on that drug for six months, due to a host of complications: nausea, aches and pains, and infections in the catheter feeding the drug to her heart. After that, she and her doctor tried different medications until, about a year ago, they hit upon the combination that works best for her: Revatio (sildenafil), and Letairis (ambrisentan).

Both drugs are vasodilators, which means they open the blood vessels and lower the blood pressure in the lungs, making it easier to breathe. The drugs, both of which Evans takes orally, have made "a world of difference," she says. "I can do almost anything I want now," although working as a chef is out because it would require her to spend too much time standing.

Rising to the Challenge of Pulmonary Hypertension

Pulmonary hypertension is a progressive, incurable disease, but Evans and Markin both warn that it's crucial to avoid succumbing to self pity or despair. "The most important thing is to be optimistic, and to have a strong-willed personality," Evans says. Both women stay as active as possible: Evans takes her dog for mile-long walks, and Markin spends 10 to 15 minutes a day on her treadmill. "When you get a disease like this, you get very, very isolated," Markin warns. "It's hard to get out and do stuff; socializing wears me out." Still, she makes a point of leaving the house every day.

Evans, who is now 27, still has enough energy to attend the live music concerts that she loves, but requires a handicapped sticker on her car and laments the outraged stares she sometimes gets from passers-by. "It's hard, because you look perfectly healthy," she explains. "People just have to take your word for how sick you are - that's probably the hardest part of it."

These women have something else in common: a wedding in their future. Evans, who is getting married in September, met her fiancée at a concert. "I'm glad I was healthy enough to go," she says. And Markin's older son is getting married in the fall, an event she'll be able to attend thanks to her persistence, optimism, and excellent care. "I'm going to be dancing with my son at his wedding," she says happily. "This is huge."

Pain and fatigue associated to the musculoskeletal system are among the leading causes of patients to visit their physicians and nearly one-third of such patients suffer from fibromyalgia. Fibromyalgia syndrome (FM) is a chronic debilitating disorder characterized by widespread pain with tenderness in specific areas, leading to fatigue, headache and sleep disorder. Myofascial Pain Syndrome (MPS), is also a localized musculoskeletal pain producing condition whose diagnostic and management criteria differ from FM but still considered by many only a subtype of FM. Till date no exact cause has been held responsible for these painful conditions, therefore treatment of these disorders is always a challenge. The therapies are not precise but multimodal including pharmacological and alternative approaches. This article describes the existing knowledge pertaining to these conditions in regard of causative factors diagnosis and management.

Introduction

Musculoskeletal system is the largest organ system by weight in the human body comprising of more than 400 skeletal muscles. Problems associated with pain or fatigue to this system are among the leading reasons for patients to visit their clinicians. Majority of these patients fall under the category of either fibromyalgia (FM) or its subtype myofascial pain syndrome (MPS). Fibromyalgia (FM) is a systemic disorder of widespread pain, a consequence of abnormal pain processing within the central nervous system (CNS). As corroborative evidence, recent studies have found increased levels of glutamate, an excitatory neurotransmitter in CNS of fibromyalgia patients. It is one of a number of overlapping functional somatic syndromes which includes chronic idiopathic lower back pain, tension headache, irritable bowel syndrome, chronic fatigue syndrome, disturbed sleep and others.

Fibromyalgia had been included in the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) along with rheumatism and fibrositis by WHO in 1992 (M 79.0) but is currently classified as a separate entity M 79.75. May 12th has been designated as the International Awareness Day for FM and other chronic immunological and neurological diseases. Thereby fibromyalgia has emerged from past obscurity and is being recognized with more importance as an "underdiagnosed" but common disease. One more condition similar to FM named myofascial pain syndrome (MPS) was described as early as 1843 but debate over its existence as a separate clinical entity from FM still continues and many consider it only a subtype of FM. It is true that the diagnostic criteria, clinical features and perhaps the etiopathogenesis of MPS differ from FM, so the treatment and prognosis. Hans et al (1999) described the differentiating features of MPS from FM. The common important feature to both conditions is muscle pain along with the taut or rope like bands in the muscles. In MPS, the painful points in the 'taut bands' are called "trigger points" (TP). These points are so precise and painful that on their palpation, patient shows a "jump sign" associated with referred pain. The "tender points" within the sore muscle of fibromyalgia are not associated with jump sign or referred pain.

Mechanism of Contraction of Skeletal Muscle

Each skeletal muscle comprises of bundle of fasicles and each fascicle is composed of about 100 muscle fibres. A muscle fibre consist of 1000-2000 myofibrils. Each myofibril is made up of chains of sarcomeres, connected end to end in a serial manner. A sarcomere is a basic contractile unit. Sarcomeres connected by "Z lines" are composed of actin and myosin molecules. Actin and myosin molecules form cross bridges in the presence of ionized calcium (Ca++). Actin-myosin bridges remain relaxed till ATP molecules are bound to myosin. Breakdown of ATP to ADP by hydrolysis causes cross-bridging of actin and myosin molecules. Soon ADP molecules leave the myosin causing it to bend which gives a pull on actin and results in shortening of sarcomere. Attachment of another ATP again relaxes the cross bridge to restart the cycle. Repetition of these cycles causes muscle to contract in presence of Ca++. Removal of Ca++ from the site causes termination of contraction. If additional ATP is not provided because of any reason the cross bridges remain attached and the muscle remains taut or stiff.

Reduced calcium metabolism in the sarcoplasmic reticulum can give rise to a trigger point in a resting muscle similar to a sustained contraction or "tetany". Ca++ release through the sarcoplasmic reticulum is controlled by release of acetyl choline at the motor end plate. The TPs of MPS are initially involved with motor end plates8. This pain can be relieved by stretching back the sarcomere, thus removing the overlap of actin and myosin and restoring the muscle length.

Factors Generating Trigger Points:

No single factor can be held responsible for the production of TPs. The possible causes are mentioned below.

1. Trauma to: - musculoskeletal system, -intervertebral discs
2. Inflammatory conditions e.g. cholecystitis, appendicitis, gastritis
3. Myocardial ischemia
4. Excessive or lack of exercise and malpositions
5. Generalized fatigue, lack of sleep and emotional stress
6. Hormonal changes as in post menopausal syndrome
7. Nutritional deficiencies
8. Intense cooling of body areas … as sleeping in front of A.C.
9. Obesity
10. Use of tobacco

Types of Trigger Points:

1. Active TP: It is a classical TP which is present within a taut band of muscle giving rise to a "Jump sign" on palpation.


2. Latent TP: In this case the patient may present a nodular area in a taut band within muscle but does not produce pain on palpation. It is a dormant area that can potentially behave like an active TP later on.


3. Secondary TP: It is a hyperirritable point in a muscle that becomes active as a muscular overactivity of another muscle.


4. Satellite myofascial point: It is a hyperirritable spot that becomes active because the muscle harbouring it is located within the region of another TP.

Treatment of MPS and FMS:

Although many theories have been put forward no clear causative factors responsible for MPS and FM have been isolated. Association of prolonged static postures, lack of exercise, high body mass index (BMI), sleep disturbance and emotional stress have been found. The treatment at present described for these conditions is therefore multimodal in nature and can be categorized as Pharmacological and Non-pharmacological therapies. The present practice combines non-pharmacological approaches with short term pharmacological therapies for longer lasting and maximal benefits.

Pharmacological Therapies:

Non pharmacological approaches may be common to both conditions but pharmacological managements of MPS and FM differ.

MPS:

• Trigger point injections: Injection of TPs with 3% promethazine hydrochloride, 0.5% Procaine or 1% plain lignocaine have been advocated. This therapy is effective when there are only few and precisely located TPs. International Association for the Study of Pain (IASP) recommends some standards and precautions while injecting TPs.


• Spray and stretch with vapocoolant: The physician uses a heating pad or moist heat on the area for 5-10 min after stretching the affected muscle (around TP). The skin is then sprayed with repeated parallel sweeps of vapocoolant slowly at 10 cm/sec speed and not exceeding two passes over the same area. Some physicians prefer "spray-stretch-spray" sequence. In place of moist heat ice- stroking and coolant like fluorimethane have also proven useful. Fluori-methane is being replaced by liquid nitrogen or ethylchloride since the former causes damage to the ozone layer.


• Topical analgesics: Sprays, sport creams and ointments having analgesic properties can be useful to control MPS's pain. Topical application of menthol, peppermint, eucalyptus oil, capsaicin and other herbal preparations can also relieve pain. Capsaicin applied topically degranulates and depletes the substance P store in nerve endings, thereby decreasing pain. Clinical trial of Capsaicin 0.1% (500mcg) hydrogel 2.5 cm diameter patch applied over TPs for cervical myofascial pain is in the second phase.


• Glucosamine and Methylsulfomethane: When taken orally for a prolonged period they are beneficial owing to their anti-inflammatory and muscle relaxing properties. Many other nutrients e.g. vitamin E, vitamin C, Zinc, Copper and herbal preparations have also been advocated. Recently L-acetyl Carnitine has been found to be effective in fibromyalgia patients.


• NSAIDS: These medications are given only for a short period especially in acute stages to reduce pain and inflammation and to enhance relaxation. They have not been proven to increase healing of affected areas. A number of analgesics and anti-inflammatory drugs e.g. aspirin, acetaminophen, ibuprofen are available with their merits and demerits.


• Botulinum toxin (botox) has been used with mixed results. Injection directly in the TP produces inconsistent effects. Early reports suggest its use in correcting abnormal biomechanics that incite a myofascial response.

Fibromyalgia:

Fibromyalgia shares common underlying neurobiological mechanisms along with physical, cognitive and behavioral co-morbidities. Pain in FM is supposed to be "central" in origin; the pain relievers like NSAIDS and opioids which are effective on "peripheral" pain are not so effective in this condition. Antidepressants, antiepileptic drugs and a number of neuroactive compounds seem to be more effective in this sort of pain.

• Oral pregabalin, a Ca++ channel a (2) o subunit ligand with antiepileptic, analgesic and anxiolytic properties has recently been approved in USA for FM.


• Oral antidepressant drugs like duloxetine and milnacipran the combined noradrenaline and serotonin uptake inhibitors are quite effective as pain relievers in FM. Duloxetine in the dosages of 60-120 mg/day for a long period and milnacipran 200 mg/day for 27 weeks30 appear to be safe, well tolerated and efficacious.


• Tropisetron, a 5 HT3 receptor antagonist may also provide significant pain relief but requires i.v route.


• Pramipexole, a dopamine (DA3) receptor antagonist in the dosages of 4.5 mg/day for weeks also causes improvement in pain, fatigue & global status.


• Mirtazepine, which blocks a2 auto (NA) and heteroreceptors (5HT) is also a promising antidepressant drug that has been proven useful.


• Central muscle relaxants may be combined with analgesics especially in back pain when it is thought to be due to muscle spasm. Cyclobenzaprine, carisoprodol, tizanidine, methocarbamol and metaxalone are the examples of centrally acting muscle relaxants. Adverse effects e.g. dizziness, drowsiness and drug abuse restricts their use only for a short term.

Non-Pharmacological Therapies:

Due to lack of definitive etiological elucidation and treatment of FMS many alternative approaches have been advocated by pain therapists. The popular approaches have been mentioned below:

• Choosing correct chair, mattress, and posture to sit or sleep.


• Back braces can be used to stabilize the vertebral column or support fatigued muscles.


• Traction devices can be used carefully as a temporary pain relief method.


• Mechanical massage: Regular massage by the devices available can penetrate deeply through a tapping or percussion action dispersing lactic acid in the soft tissue causing improvement in circulation and relaxation of knotted muscles.


• Whole body vibration with traditional exercise programme for six weeks was also found to reduce pain and fatigue score.


• Chiropractic management combined with aerobic exercises and cognitive behavioral therapy, acupuncture and spa therapy also have strong evidences in their favour.


• Yoga: Regular yogic breathing practices, muscle stretching and progressive deep relaxation by "shavasana" are known to have positive effect on FM.


• Ischaemic acupressure or 'Shiatsu': In this technique the clinician applies thumb pressure (TP) in a particular manner for 1 minute. In next minute the pressure is increased suddenly aggravating pain and a sensation of "giving away" is felt underneath the thumb in muscle as the pressure is released gradually.


• Hot and cold therapies:
• Cold and hot packs: Ice packs can reduce inflammation and pain if applied within 72 hrs of an injury. Ice should not be applied in a single area for more than 20 mins owing to 'reverse reaction' phenomenon.


• Hot packs are effective if applied after third day of injury. Moist heat is believed to be better in pain and inflammation improvement.


• Whirlpool and Jacuzzi jet massaging therapy are also examples of moist heat treatment.


• 'Waon' (soothing warmth) therapy employs far infrared ray dry sauna bath at 60° C for 15 min followed by transferring the patients to a room at 26° C covered with blanket for 30 min. Such 2-5 cycles in a week have significant effects on pain reduction.

• Electrical stimulation: Such devices also prove effective but under medical supervision. Often called "dry needling" the technique of electrical stimulation by a needle passed in to TP has been successfully demonstrated to relieve shoulder and cervical myofascial pain as well as improve microcirculation.


• Ultrasound therapy: Sound waves from ultrasound machine are transmitted through sound conducting gel to the tissues. The ultrasound waves break down scar tissue, relax muscle and improve local circulation.


• Laser therapy: Short period application of infrared low level 904 nm Ga-As laser therapy have been found to be effective in pain relief and functional ability but its benefit when combined with muscle stretching physiotherapy has been questioned. The underlying causes of fibromyalgia and myofascial pain syndrome are not yet fully understood and there still remains a controversy about the independent existence of MPS but a high distressing incidence prevails in human population. The acceptance and awareness of these complex disorders has generated the need of new researches in all medical and paramedical fields. At present the combined and collective approaches hold the key to the management of fibromyalgia.

We all know that maintaining a healthy lifestyle right now can mean a longer, higher-quality of life in the long run. Yet for many, adopting health-focused habits sounds about as enjoyable as an algae and flax milkshake. However, incorporating the following tips into your daily routine can make leading a longer, happier life much simpler. Plus, many of these healthy lifestyle guidelines go hand in hand, so when you start with one or two, it's easier to adopt many of the rest.

Eat Right

A healthy diet is all about variety and moderation, says Dee Sandquist, M.S., R.D., spokesperson for the American Dietetic Association (ADA) and director of nutrition, diabetes, weight management, and wound healing at Southwest Washington Medical Center. Because varying the foods you eat can help reduce your risk of developing a chronic disease, Sandquist recommends the following equation: "Make half your grains whole grains, vary your veggies and fruits, go lean with protein and get calcium-rich foods." Stick with this philosophy, and you'll automatically get all the buzzed-about nutrients and antioxidants that can help combat early aging. And by moderating the amounts of sodium, cholesterol, and sugar you eat, you'll have plenty of room for nutritious foods.

Stay at a Healthy Weight

"Maintaining a healthy weight will reduce your risk of chronic disease and help you to feel better so that your quality of life will be greatly improved," says Sandquist. One technique for determining whether you're in a healthy weight range is to measure the smallest part of your waist above the hips. Sandquist recommends that men measure less than 40 inches and women less than 35 to reduce the risk of such chronic conditions as heart disease, stroke, diabetes, and cancer.

Make Activity a Must

Incorporating activity into most if not all days of the week is a must for adding years to your life. Not only does regular exercise help stave off heart disease, high blood pressure, osteoporosis, diabetes, obesity and depression - but moving regularly makes it easier to remain active well into your senior years by keeping tendons, ligaments, and joints flexible and healthy. The American Academy of Family Physicians recommends working in 30 to 60 minutes of physical activity at least four to six days per week - a combination of aerobic, strength, and flexibility training is best. If that sounds too daunting, try sneaking in snippets of activity whenever you have a free moment. A few 10-minute walks a day are better than nothing at all. To ensure that you stick with it, just be sure to vary your routine with activities that you enjoy.

Flex Your Mental Muscles

A study funded by the National Institute on Aging (NIA) found that people who most often participated in information-processing activities, such as listening to the radio, reading newspapers, playing puzzle games, and visiting museums were 47% less likely to develop Alzheimer's disease than those who participated least often in these same activities. The reason? "If you sit around and don't exercise a muscle, it atrophies - and the same goes for the brain," says Dr. Kimford Meador, MD, fellow with the American Academy of Neurology (AAN) and professor of neurology at the University of Florida. So get your brain working by engaging in mental stimuli that you enjoy. Mind exercises can be anything from reading a good novel to playing cards to working through crossword or Sudoku puzzles.

Ditch the Habit

If you're a smoker, the U.S. Surgeon General counts this as the "single most important step" that you can take to enhance the length and quality of your life. Quitting smoking can decrease your chances of many diseases, including a long list of cancers (bladder, cervix, esophagus, kidney, larynx, lung, mouth, pancreas, stomach, throat and some forms of leukemia), as well as heart attack, stroke, and emphysema. In fact, the U.S. Centers for Disease Control and Prevention (CDC) estimates that male non-smokers can add 13.2 years to their life expectancy and female non-smokers can hold on to 14.5 more years than smokers. If you need help quitting, call the American Cancer Society at 1-800-ACS-2345 for a list of support groups or telephone-based quit lines in your area.

Stop Stressing

Not only can stress make your Fibromyalgia, CFS/ME and heart work overtime, but it can literally make you age faster. According to Dr. Jay Winner, author of Take the Stress Out of Your Life and founder and director of the Stress Management Program for Sansum Clinic in Santa Barbara, studies have shown that stress can actually alter a person's DNA, aging them beyond their years. Dr. Winner suggests first trying to let go of obvious stressors that you have control over. Not possible to ditch your stressful job right now? Then learn to cope with your reality. Take five minutes at work to stop and focus on your breath. Or if standing in line at the grocery store is causing your blood pressure to skyrocket, grab a magazine and take those five minutes to relax. And remember to be grateful for what you do have, like good health and a great family. Putting things in perspective will help you realize there are more important things to invest your mental energy in than a nasty case of road rage.

Get Your Rest

Catching enough zzzs can tack years onto your life. According to the National Institutes of Health, adults who consistently get less than seven hours of sleep per night are at higher risk for conditions like hypertension, heart disease, obesity, diabetes, and depression. Plus, not getting a good night's sleep prevents the release of vital hormones that repair cells and tissues and fight sickness and infection, keeping your body from its natural healing processes. So don't think of it as sleeping your life away. Using the evening hours for a good snooze will actually give you the chance to enjoy more of life.

Slather on the SPF

The Centers for Disease Control and Prevention (CDC) has found that UV rays from the sun are the leading environmental cause of skin cancer — the most common type of cancer in the United States. So before you step outside, bulk up your defenses by applying sunscreen with an SPF of 15 or greater that protects against both UVA and UVB rays. The American Cancer Society recommends using at least a palmful for your entire body, and reapplying every two hours while you're out in direct sunlight, especially after you've been swimming or if you've been sweating at lot.

Screen for the Big Three

A routine cancer screen can identify certain cancers before symptoms occur, when your chances of beating the disease are greatest. The "big three" to screen for regularly include breast, cervical, and colorectal cancers. The CDC recommends that women get regular clinical and self breast exams by age 20 and mammograms to test for breast cancer every one to two years after the age of 40. In addition, women should have a regular Pap smear starting at age 21 or within three years of first having sex to check for cervical cancer. For both men and women, the CDC recommends a colorectal cancer screening soon after turning 50, then routinely after that. Catching these types of cancer early can make treatment more effective, giving you a better chance at that long, healthy life.

Be a Social Butterfly

Severe stress and depression can have negative effects on parts of the brain like the hippocampus, which is vital for memory retention, says Dr. Meador. On the flipside, Dr. Meador suggests that maintaining strong, supportive relationships can be beneficial to both mental and emotional health. Need another reason to beef up your social circuit? The NIA has found that social engagement can significantly reduce cognitive decline and dementia. So be sure to keep your friends and family on speed dial and consider accepting all your social invitations. While seemingly inconsequential, that friendly chitchat could be helping to keep your mind young and engaged.

Australia Day, also known as Anniversary Day and Foundation Day, is the official national day of Australia. Celebrated annually on 26 January, the day commemorates the arrival of the First Fleet at Sydney Cove in 1788, the unfurling of the British flag there, and the proclamation of British sovereignty over the eastern seaboard of Australia.

Australia Day is an official public holiday in every state and territory of Australia, and is marked by the Order of Australia and Australian of the Year awards, along with an address from the Prime Minister.

Records of the celebration of Australia Day date back to 1808, with Governor Lachlan Macquarie having held the first official celebration of the formation of New South Wales in 1818. In 2004, an estimated 7.5 million people attended Australia Day celebrations and functions across the country.

Australia Day is seen as controversial by some historians. Alongside proposals to change the date of Australia Day, there have been significant protests from the Indigenous Australian community. Many Indigenous Australians see Australia Day as a celebration of the destruction of Indigenous culture by British colonialism. Since 1988, "Invasion Day" protests have been held supporting this view. In light of these concerns, proposals to change the date of Australia Day to other dates have been made.

Carbohydrates are an important part of your diet, but that doesn't mean you're free to load up on cakes and cookies to get your daily amount. Find out the difference between good and bad carbohydrates.

Carbohydrates and Your Diet

Carbohydrates, better known as "carbs," are your body's primary energy source, and they're a crucial part of any healthy diet. Carbs should never be avoided, but it is important to understand that not all carbs are alike.

Carbohydrates can be either simple (nicknamed "bad") or complex (nicknamed "good") based on their chemical makeup and what your body does with them. Complex carbohydrates, like whole grains and legumes (beans/peas), contain longer chains of sugar molecules; these usually take more time for the body to break down and use. This, in turn, provides you with a more even amount of energy, according to Sandra Meyerowitz, MPH, RD, a nutritionist and owner of Nutrition Works in Louisville, Ky.

Simple Carbohydrates - "Bad Carbs"

Simple carbohydrates are composed of simple-to-digest, basic sugars with little real value for your body. The higher in sugar and lower in fiber, the worse the carbohydrate is for you - remember those leading indicators when trying to figure out if a carbohydrate is good or bad.

Fruits and vegetables are actually simple carbohydrates - still composed of basic sugars, although they are drastically different from other foods in the category, like cookies and cakes. The fiber in fruits and vegetables changes the way that the body processes their sugars and slows down their digestion, making them a bit more like complex carbohydrates.

The most important simple carbohydrates to limit in your diet include:

• Soda
• Candy
• Artificial syrups
• Sugar
• White rice, white bread, and white pasta
• Pastries and desserts
• Potatoes (technically a complex carb, but act more like simple carbs in the body)

Meyerowitz says that you can enjoy simple carbohydrates on occasion, you just don't want them to be your primary sources of carbs. And within the simple carb category, there are better choices - a baked potato, white rice, and regular pasta - than others - chips, cakes, pies, and cookies.

Complex Carbohydrates - "Good Carbs"

Complex carbohydrates are considered "good" because of the longer series of sugars that make them up and take the body more time to break down. They generally have a lower glycemic load, which means that you will get lower amounts of sugars released at a more consistent rate - instead of peaks and valleys - to keep you going throughout the day.

Picking complex carbohydrates over simple carbohydrates is a matter of making some simple substitutions when it comes to your meals. "Have brown rice instead of white rice, have whole-wheat pasta instead of plain white pasta," says Meyerowitz.

To know if a packaged food is made of simple or complex carbohydrates, look at the label. "Read the box so you know what exactly you're getting. If the first ingredient is whole-wheat flour or whole-oat flower, it's likely going to be a complex carbohydrate," says Meyerowitz. "And if there's fiber there, it's probably more complex in nature."

The Glycemic Load Factor

Describing carbs as being either simple or complex is one way to classify them, but nutritionists and dietitians now use another concept to guide people in making decisions about the carbs they choose to eat.

The glycemic index of a food basically tells you how quickly and how high your blood sugar will rise after eating the carbohydrate contained in that food, as compared to eating pure sugar.

Lower glycemic index foods are healthier for your body, and you will tend to feel full longer after eating them. Most, but not all, complex carbs fall into the low glycemic index category.

It is easy to find lists of food classified by their glycemic index. You can see the difference between the glycemic index of some simple and complex carbohydrates in these examples:

• White rice, 64
• Brown rice, 55
• White spaghetti, 44
• Whole wheat spaghetti, 37
• Corn flakes, 81
• 100 percent bran (whole grain) cereal, 38

To take this approach one step farther, you want to look at the glycemic load of a food. The glycemic load takes into account not only its glycemic index, but also the amount of carbohydrate in the food. A food can contain carbs that have a high glycemic index, but if there is only a tiny amount of that carb in the food, it won't really have much of an impact. An example of a food with a high glycemic index but a low glycemic load is watermelon, which of course tastes sweet, but is mostly water.

The Bottom Line

Just be sensible about the carbs you choose. Skip low-nutrient dessert, consider the levels of sugar and fiber in carbs, and focus on healthy whole grains, fruits, and veggies to get the energy your body needs every day.

Objective
To determine the frequency and severity of gastrointestinal (GI) symptoms in patients with fibromyalgia (FM).

Methods
We included 152 women with FM (mean age 45.4 ± 12.2 yrs), 98 women with rheumatoid arthritis (RA; mean age 45.5 ± 12.3 yrs), and 60 healthy female controls (mean age 44 ± 11.3 yrs). All patients were questioned about the severity of their chronic widespread pain, symptoms of FM, symptoms of dyspepsia, using a visual analog scale (VAS), and anxiety-depression scale. Patients were asked self-reported (yes/no), symptom-based (≥ 2 criteria) constipation and severity of constipation questions, and about the severity of quality of life (QOL) disturbance secondary to dyspepsia and constipation.

Results
Patients with FM had higher symptom severities for belching, reflux, bloating, sour taste, and vomiting than patients with RA and controls (all p values < 0.01). Patients with FM had significantly more dyspepsia-related QOL disturbances than the other 2 groups (p < 0.01). FM and RA patients had more frequent self-reported constipation than controls (respectively, 42.1%, 48%, 21.7%; p < 0.01). The frequency of symptom-based constipation was significantly higher in the RA group (49%) than in FM (29.6%) and control groups (23.3%) (p < 0.01). Constipation-related QOL disturbance was significantly higher in patients with FM than in controls (p < 0.01).

Conclusion
In patients with FM, the severity scores of dyspepsia symptoms, constipation, and dyspepsia-related QOL disturbance were higher than in patients with RA and controls. The higher GI symptom severity in patients with FM might have negative effects on their QOL.

Fibromyalgia (FM) pain is frequent in the general population but its pathogenesis is only poorly understood. Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition. However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both.

It is well known that persistent or intense nociception (the neural processes of encoding and processing noxious stimuli) can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain. This mechanism represents a hallmark of FM and many other chronic pain syndromes including:

• irritable bowel syndrome
• temporomandibular disorder
• migraine
• and low back pain

Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state.

Additional factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of FM and other chronic pain syndromes.

A husband and wife are shopping in their local Wal-Mart.The husband picks up a case of Budweiser and puts it in their cart.

'What do you think you're doing?' asks the wife.

'They're on sale, only $10 for 24 cans,' he replies.

'Put them back, we can't afford them,' demands the wife, and so they carry on shopping.

A few aisles further on along the woman picks up a $20 jar of face cream and puts it in the basket.

'What do you think you're doing?' asks the husband.

'Its my face cream. It makes me look beautiful,' replies the wife.

Her husband retorts: 'So does 24 cans of Budweiser and its half the price.'

On the PA system: 'Cleanup needed on aisle 25, we have a husband down'

JANUARY 2010

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