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The Sad State of Pain Management
Sunday November 2, 2008
If you have chronic pain from fibromyalgia (FMS), chronic fatigue syndrome (CFS or ME/CFS), or any other cause, you've probably been frustrated at some point with the quality of pain treatment you've gotten from a doctor.
There's a good reason for that. Even though pain is the most common complaint doctors hear, most doctors aren't terribly well equipped to assess and treat it. Why is that? During all those years of medical school, the American Pain Foundation says medical schools spend about one hour teaching young physicians to understand and treat pain. One hour, on a topic that can derail your life.
According to a study published in the New England Journal of Medicine, one third of hospital patients felt their pain was not well controlled. It's no wonder that those of us who only get a doctor's ear for a few minutes a few times a year, and aren't typically observed by health-care providers when we're at our worst, have less-than-adequate pain control.
Here are some statistics I find interesting, not to mention troubling:
* At least 76 million Americans are in chronic pain
* Pain costs the U.S. about $100 billion a year in medical care and lost productivity
* The U.S. has an estimated 1 pain specialist for every 21,000 pain patients
* Only 2% of NIH research money is spent on pain studies
On top of all that, in spite of everything researchers have learned in recent years about pain and pain relief, pain treatment has hardly improved at all.
How can we use this information, other than to fuel our anger and frustration? In a couple of ways. First, on a personal level, we can understand what both we and our doctors are up against, work to improve our communication with them, and push for the pain management we need. Second, on a broader level, we can support the efforts of advocacy groups working to secure more research funding and better physician education. Here are some articles that can help you with both of these things:
* Improve Communication with Your Doctor
* Top 10 Advocacy & Awareness Groups for Fibromyalgia & ME/CFS
http://chronicfatigue.about.com/b/2008/11/02/the-sad-state-of-pain-management.htm?p=1
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The following article can be found:
http://www.prohealth.com/fibromyalgia/modalities.cfm?B1=CHWEBO
Pharmaceutical
Two pharmaceutical drugs have been approved by the FDA for the treatment of fibromyalgia: Lyrica and Cymbalta. Lyrica is an anticonvulsant that binds to a specific protein within overexcited nerve cells and works to calm damaged nerves. This is thought to reduce the level of pain in FM patients. Cymbalta is a serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant. It is thought to work by increasing the activity of serotonin and norepinephrine in the central nervous system. These are two neurochemicals known to be low in FM patients.
Other medications may be prescribed off-label to treat FM symptoms. Some of these include:
* Anticonvulsants – for pain, sleep and mood stabilization
* Antidepressants (SSRI, SNRI or tricyclic) – for depression, sleep and pain
* Sleep initiators and sustainers
* Analgesics (NSAID, Cox II inhibitor, opioid, topical) – for pain
* Stimulants – for energy improvement and mental acuity
* Muscle Relaxants – for pain and sleep
People with fibromyalgia are often highly sensitive to medications, therefore, dosages should usually started at low levels and gradually adjusted to a level that is both well-tolerated and therapeutic.
Every patient is different. What works for one may not work for another. Physicians and patients need to work together to discover which drug, or combination of drugs, works best.
Supplements & Herbs
Many fibromyalgia patients take a variety of supplements and herbs along with, or sometimes instead of, pharmaceutical drugs. Because FM patients are often sensitive to medications, supplements and herbs can provide a healthy, helpful alternative.
Recent research has shown vitamin D to be particularly effective for the musculoskeletal pain of fibromyalgia. (See “Vitamin D – A Neglected ‘Analgesic’ for Chronic Musculoskeletal Pain” )
Other supplements often used for various FM symptoms include:
* Sleep – melatonin, valerian root, calcium/magnesium, GABA, 5-HTP
* Energy – B12, DHEA, NADH, magnesium malate, D-ribose, CoQ10
* Pain – Vitamin D, magnesium malate, white willow bark, bromelain, thiamin
* Memory – DMAE, Ginkgo Biloba, vinpocetine, Methylcobalamin (a form of B12)
Acupuncture
Acupuncture can help improve a number of fibromyalgia symptoms including pain, sleep, irritable bowel syndrome and depression. Research has shown acupuncture to be especially effective for relieving pain.
Acupuncture is one component of the 5,000-year-old practice of Chinese medicine. According to Chinese medicine, there are energetic pathways, or channels, throughout the body that influence associated internal organs and structures. Energy from these pathways surfaces at various points on the body, identified as acupuncture points. Each of these acupuncture points serves as a tunnel, or access route, to the deeper circulatory channels within. Acupuncture stimulates a selection of specific points, thereby activating the body’s natural healing abilities.
Acupuncture is safe and usually painless. The needles used are made from extremely fine gauge, flexible surgical stainless steel. (Five acupuncture needles fit inside the hole of one hypodermic needle.) Unlike hypodermic needles that cut the skin, acupuncture needles slide through the skin without cutting. Only sterile, single-use needles are used.
Bodywork
Bodywork is a term used to describe alternative/complementary therapies involving touch, physical manipulation or energetic work. There are several types of bodywork that may be used to treat fibromyalgia. Like any treatment for this illness, effectiveness varies with the individual. While some report great success with a particular method, others say that same method caused a severe relapse.
Before beginning any type of bodywork, make sure the practitioner is certified in her field and knowledgeable about FM. Talk with the practitioner prior to beginning treatment and ask questions so you know what to expect. Be sure to ask how many treatments it should take before you begin to have noticeable improvement.
A few of the most frequently used bodywork therapies include:
* Myofascial Release Therapy – Often considered a type of massage, myofascial release therapy consists of very gentle manipulation of the fascia (connective tissue located between the skin and underlying structure of muscle and bone). Fascia can become tight and restricted in response to injury, inflammation, stress or even poor posture. Over time, the tightness in one area can spread throughout the whole body, which can be quite painful. The goal of myofascial release is to release the restricted fascia, which in turn eases the pain, increases the patient’s range of motion, and brings the body into balance. Most FM patients who get regular myofascial release therapy treatments report significant improvement in pain levels, energy and sleep.
* Therapeutic Massage – Therapeutic massage involves the manual manipulation of the body’s soft tissue. There are as many as 80 different types of massage, each with its own purpose. While the primary goal of some massage techniques is relaxation, the aim of therapeutic massage is to help the body function better. In addition to relaxation, it can help improve circulation, reduce stress, anxiety and depression, ease muscle aches and pains, and improve sleep problems and immune system function.
* Energy Medicine – There are numerous practices that claim to promote or maintain the balance of vital energy fields in the body. Some examples include: therapeutic touch, healing touch, Reiki, Johrei, vortex healing, and polarity therapy. All of these modalities involve movement of the practitioner's hands over the patient's body to become attuned to the condition of the patient and identify energy imbalances, with the idea that by so doing, the practitioner is able to use their own perceived healing energy to strengthen and reorient the patient's energies, thereby promoting health. Often these therapies report impressive anecdotal evidence, but little scientific research has been done to verify their effectiveness.
Exercise
Exercise can be a touchy subject for fibromyalgia patients. When it hurts to move, the idea of exercising seems unfathomable. But multiple studies have shown that exercise is an important component of any FM treatment plan. Part of the problem is that most people think of exercise as jogging, aerobics and other strenuous activities. FM and ME/CFS specialist Dr. Charles Lapp suggests redefining “exercise” for FM patients. Perhaps a better word would be “movement” or “activity.” He says the main thing is to avoid strict bed rest, which causes deconditioning, which in turn makes symptoms worse.
Important FM “exercise” tips:
* Move your body as much and as often as you are able – even if it’s just walking to the kitchen for a glass of water.
* Deep breathing exercises – learning to breathe from the lower part of the diaphragm – is essential. Shallow breathing increases neck and shoulder pain and can cause chest tightness, shortness of breath and spasms in the postural muscles. Deep breathing eases tension and improves the circulation of oxygen in your body.
* Stretch your muscles periodically throughout the day. Begin slowly with seated stretches. After several weeks, if you are able, progress to standing stretches.
* When you first begin any new type of exercise, begin very slowly. Depending on the severity of your illness, start with as little as one minute and build up very gradually (i.e., spend several weeks at each level).
* Take frequent rest breaks. Try resting three minutes for each minute of exercise. Once you’ve moved into strength training or cardiovascular exercise, it’s a good idea to only exercise every other day, allowing yourself a day of rest between workouts.
* Break up your exercise sessions. Five three-minute sessions are better for FM patients than one fifteen-minute session.
* For those who are able to tolerate a longer period of exertion, water exercise may be a good option. Water’s buoyancy decreases the effects of gravity, displacing 85 percent of your weight. As a result, it takes less effort to move because you don’t have to support your whole weight. Also, immersion in water promotes relaxation, reduces muscle fatigue and lessens pain perception.
Lifestyle
Every fibromyalgia patient is forced to make certain lifestyle changes and adaptations. The key is to make the changes that will help you develop an environment that allows you to function at the best level possible and gives you the best opportunity to improve both physically and emotionally.
One of the most important changes any FM patient can make is learning to live within your “energy envelope.” Each day evaluate your energy level and imagine putting that allotment of energy into an envelope. Each time you expend energy, mentally remove that portion of energy from your envelope. When your envelope is empty, it’s time to stop. It’s often tempting to keep going, especially if you’re having a good day. But if you try to push beyond your energy envelope one day, you’re likely to crash and feel worse for several days. Learn to separate what needs to be done from what you would like to get done, and focus on the necessities first.
Other important lifestyle changes include:
* Practicing good sleep hygiene. Poor sleep is one of the biggest problems for fibromyalgia patients, but unfortunately most do not have good sleep habits. In fact, Dr. Lucinda Bateman says 80 percent of her patients actually make their sleep worse. To learn more about good sleep hygiene, read: “Sleeping Without Pills”
* Improving your diet. If possible, consult a nutritionist or dietician to determine which foods are best for you. When energy levels are low, it’s easy to fall back on fast food or frozen dinners, which seldom have the best nutritional value. On the days you cook, make extra and freeze your own nutritional meals to have on hand for the days you have no energy. Or if you’re not able to cook at all, maybe a friend or family member would make extra and freeze it to share with you. (See “The Fibromyalgia Diet: Eating for a Better Quality of Life” )
* Organizing your home to conserve energy. For example, keep a set of items you need regularly next to the chair, sofa or bed where you spend most of your time (i.e., phone, pencil, paper, nail file) so you don’t have to keep getting up to get them. Or always put your keys in the same place so you don’t have to search the house every time you need to go somewhere.
Mental Health
Living with a chronic illness like fibromyalgia is difficult at best. The physical distress and hormonal imbalances coupled with drastic lifestyle changes can easily result in depression and anxiety. Your doctor may prescribe antidepressant or anti-anxiety medication and/or refer you to a psychiatrist or psychologist, who can help you learn to cope with all the changes.
If your insurance doesn’t cover mental health treatment and you cannot afford it, check with your local mental health center. They usually offer treatment on a sliding scale based on your income.
Many FM patients find that support groups offer them the encouragement and support they need. Search for a support group in your area in ProHealth’s Support Group Listing. If you don’t find a group there, try calling local hospitals and your local newspaper to see if they know of any groups in your area.
If you’re not able to physically attend a support group, there are lots of online groups available. In fact, you can start interacting with other FM patients right now in ProHealth’s FM Chat Room or the FM Message Board.
Other
A vast number of different modalities are used in the treatment of FM. Some are quite traditional, while others are somewhat unusual. Many are controversial. It’s impossible to predict which treatment is best for you because what works for one person may or may not work for another. Study the various options and be sure to talk with your healthcare provider before beginning any new treatment.
A few other treatment modalities you’ve probably heard about include:
* Physical Therapy – Carefully supervised physical therapy may be helpful for fibromyalgia, but it is essential that the therapist be very knowledgeable about the illness and care be taken to avoid doing too much at one time.
* Biofeedback – This mind-body therapy designed to teach you to use your thoughts and will to control your body. It is based on the idea that people have the innate ability to influence many of the automatic functions of their bodies and has been confirmed by scientific studies. A biofeedback specialist uses special monitoring equipment to measure responses, such as heart rate, blood pressure, muscle tension, skin temperature and brain activity. Using these measurements, he teaches you to recognize your reactions to thoughts so you can learn to control those reactions.
* Cognitive Behavioral Therapy (CBT) – CBT is one of the more controversial fibromyalgia treatment modalities because it is basically a psychological technique and is strongly supported by those who still insist on believing that FM is primarily a psychological problem. The treatment focuses on maladaptive patterns of thinking and the underlying beliefs. For example, a person who is depressed may have the underlying belief that he is worthless. While CBT is certainly not a cure for the physical illness fibromyalgia, it can be a helpful tool for treating symptoms like depression and anxiety.
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Below article is from: http://www.everydayhealth.com/fibromyalgia/101/new-research.aspx
New Research May Be Clue to Fibromyalgia Diagnosis and Treatment
Key brain chemical may be critical to understanding fibromyalgia symptoms
by Linda Melone
Fibromyalgia and its varying array of symptoms often baffle patients and physicians alike. There is still no widely accepted diagnostic blood test or other biomarker for the disease, even though sufferers report life-altering physical limitations. Now, new research at the University of Michigan is linking the broad range of fibromyalgia symptoms to a brain molecule called glutamate, opening the door to new treatment options and more precise methods of diagnostic testing.
Fibromyalgia: New Evidence May Help With Diagnosis
Symptoms of fibromyalgia run the gamut from extreme fatigue and flulike body aches to digestive ills and migraine headaches. Due to the absence of a specific quantitative or qualitative test, however, physicians have long been forced to rely on a patient's self-report to help diagnose this elusive condition. For this reason, some doctors didn't take the malady seriously.
Groundbreaking research done in 2002 by Daniel Clauw, M.D., professor of medicine and associate dean at the University of Michigan, provided the first solid biological and physical evidence that fibromyalgia patients really felt intense pain when they said they did. A form of brain imaging called a functional MRI (fMRI) showed that those with fibromyalgia were much more sensitive to pain than those in a control group; similar levels of pain also caused different areas of the brain to light up in the FM group than in the control group.
The widespread nature of the chronic pain associated with fibromyalgia — pain not specific to any one group of muscles or joints — is currently under investigation. "Most physicians believed fibromyalgia was a peripheral issue, involving the muscles and joints, because that's what patients experienced and reported," says Richard Harris, Ph.D., research investigator in the Department of Internal Medicine's Rheumatology division at the University of Michigan Medical School, as well as a researcher at the university's Chronic Pain and Fatigue Research Center; and a colleague of Dr. Clauw. "Findings from our new research suggest that fibromyalgia may be more of a central nervous system condition. This makes it harder for critics to explain away the findings—patients can't fake an MRI test result once it becomes more widely available for fibromyalgia diagnosis."
Fibromyalia: Glutamate Linked to Pain
Dr. Harris and other University of Michigan researchers found that pain levels in fibromyalgia patients coincided with the levels of glutamate, an amino acid and neurotransmitter (brain chemical) responsible for stimulating nerve cells. "When patients were given treatments designed to reduce their pain, glutamate levels went down in a corresponding way," Harris explains.
Earlier research showed a link between excitement in a part of the brain called the insula (insular cortex) and pain in fibromyalgia sufferers. The insula region is also involved with stimuli from muscles and skin in addition to internal sensations like the bowel. This association may help explain the incidence of digestive problems, such as irritable bowel syndrome, in fibromyalgia. Other fibromyalgia-associated conditions, such as anxiety and migraine headaches, may also be linked to the central nervous system's involvement, according to Andrew Holman, M.D., rheumatologist and assistant clinical professor of medicine at the University of Washington.
Fibromyalgia: Research Leads to New Medications
New medications are now available for use in treating fibromyalgia symptoms thanks to this research. "The Food and Drug Administration recently approved pregabalin (Lyrica) and duloxetine (Cymbalta), two medications that both work centrally, as a direct result of the new research," says Dr. Holman. "Fibromyalgia has its own process, but the problems of the autonomic nervous system that cause Stage 4 sleep deprivation [a symptom of fibromyalgia] originate in the same areas of the brain that are responsible for such issues as bowel motility [which relates to IBS] and the basic fight or flight syndrome [which relates to anxiety symptoms]."
Although these findings validate many of the more subtle symptoms experienced by fibromyalgia patients, more research is needed before fMRI and PET scan testing becomes part of a routine diagnosis, says Harris. Until then, Harris stresses the importance of being aware of your symptoms and managing them appropriately. "Fibromyalgia is not one of those conditions where you can do one thing and then you're done," he notes. "It's a matter of managing symptoms through a multifaceted approach."
Last Updated: 08/15/2008
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i wanted a little advice on what other sufferers think about the importance of taking muscle relaxers? ive tried quite a few,to me they seem to just make me more tired than i already am,and dont seem to do anything for the pain.i wonder if i should even take one at all.the ones i tried were: soma=made me feel spaced out,then a headache later. flexeral=made me super tired,and extremely dry mouth.
valium=seem to help with anxiety more than relax muscles.
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September 21, 2007 — The European League Against Rheumatism (EULAR) has issued the first guidelines for the treatment of fibromyalgia syndrome (FMS) and published them in the September 17 Online First issue of the Annals of the Rheumatic Diseases.
"Although effective treatments are available no guidelines exist for management of FMS," write Serena F. Carville, from King's College London, United Kingdom, and colleagues. "The objectives were to ascertain the strength of the research evidence on effectiveness of treatment of FMS and develop recommendations for its management based on the best available evidence and expert opinion to inform healthcare professionals."
Of 146 studies eligible for review, 39 pharmacologic intervention studies and 59 nonpharmacologic studies were used to create the final recommendation summary tables, after those of lower quality or with insufficient data were excluded. Identified categories of treatment were antidepressants, analgesics and "other pharmacological," and exercise, cognitive behavioral therapy, education, dietary interventions, and "other nonpharmacological interventions."
Specific recommendations in these guidelines regarding general considerations for management of FMS are as follows:
Comprehensive evaluation of pain, function, and psychosocial context is needed to understand FMS completely, because it is a complex, heterogeneous condition involving abnormal pain processing and other secondary features (level of evidence, IV D).
Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of nonpharmacologic and pharmacologic interventions. After discussion with the patient, treatment modalities should be specifically tailored based on pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance (level of evidence, IV D).
Specific recommendations on nonpharmacologic management of FMS are as follows:
Heated pool treatment, with or without exercise, is effective (level of evidence, IIa B).
For some patients with FMS, individually tailored exercise programs can be helpful. These may include aerobic exercise and strength training (level of evidence, IIb C).
For certain patients with FMS, cognitive behavioral therapy may be beneficial (level of evidence,IV D).
Based on the specific needs of the patient, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated (level of evidence, IIb C).
Specific recommendations on pharmacologic management are as follows:
Tramadol is recommended for management of pain (level of evidence, Ib A). Although other treatment options may include simple analgesics (eg, paracetamol) and other weak opioids, corticosteroids and strong opioids are not recommended (level of evidence, IV D).
Antidepressants are recommended for the treatment of FMS because they decrease pain and often improve function (level of evidence, Ib A). Appropriate options may include amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole.
Tropisetron, pramipexole, and pregabalin are recommended for the treatment of FMS because they reduce pain (level of evidence, Ib A).
Limitations of these recommendations are that some are based only on expert opinion; basis from clinical trial data limited to changes in pain measured by the VAS and function evaluated with the FIQ; failure to consider positive effects on other outcome measures of pain or on function evaluated with different instruments; and high variability in outcome measures used, results reporting, and poor methodologic quality precluding meta-analysis.
Ann Rheum Dis. Published online September 17, 2007.
Clinical Context
The predominant rheumatologic features of FMS include chronic, widespread pain and lowered pain threshold, with hyperalgesia and allodynia. Other features often accompanying FMS include fatigue, depression, anxiety, sleep problems, headache or migraine, bowel irregularity, diffuse abdominal pain, and urinary frequency.
Of 146 eligible studies reviewed, those of lower quality or with insufficient data were excluded, and 39 pharmacologic and 59 nonpharmacologic studies were used to create the 9 final recommendations.
The 9 recommendations included 8 management categories, 3 of which had strong evidence from the current literature, and 3 that were based on expert opinion.
The 9 recommendations were as follows:
Comprehensive evaluation of pain, function, and psychosocial context are needed to understand FMS completely, because of its complex, heterogeneous nature.
Optimal treatment of FMS mandates a multidisciplinary approach, including nonpharmacologic and pharmacologic interventions. Treatments should be specifically tailored to patient reports of pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance.
Heated pool treatment, with or without exercise, is effective. Individually tailored exercise programs, which may include aerobic exercise and strength training, may be helpful for some patients.
Cognitive behavioral therapy, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated for certain patients.
Tramadol is recommended for management of pain from FMS. Simple analgesics (eg, paracetamol) and other weak opioids may be considered, but corticosteroids and strong opioids are not recommended.
Antidepressants are recommended to decrease pain and improve function (eg, amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole).
Tropisetron, pramipexole, and pregabalin are recommended to reduce pain of FMS.
EULAR plans to update the guidelines every 5 years and incorporate findings from good-quality clinical trials that will add to currently available evidence.
Pearls for Practice
Pharmacologic interventions recommended for FMS include tramadol for pain management, with simple analgesics and weak opioids if needed. Corticosteroids and strong opioids are not recommended. Antidepressants are recommended to decrease pain and improve function.
Nonpharmacologic interventions recommended for FMS include comprehensive evaluation; multidisciplinary, specifically tailored therapy; and heated pool treatment, with or without exercise. Individually designed exercise programs, cognitive behavioral therapy, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be helpful for some patients.
Thought some DB members outside of US might appreciate this as they would be impacted by the guidelines. Color highlight are mine
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ok, don't flame me. what exactly is fibro?
the people who are fibromyalgic would be best to describe it to me, rather than wikipedia and other internet sources.
i am under the impression that it is almost an unbearable pain (be it in the abdomenal area or throughout the body.)
ok, the real reason i ask is that some days all i feel like doing is smoking and staying in bed to avoid the agony of movement.
i don't think that i suffer from this relatively new diagnosis, but i have never been able to find consistent information on this subject.
again, don't flame me--i am only looking for answers. did kcob suffer from fibro? it at least seems that the pain he talked about was indeed chronic and severe.
-bones
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Hi everyone. I have fibromyalgia. I've been suffering for 9 months. My doctor told me today that the 5/500 mg Lortab that I recieved for TWO months would not be refilled. He said that other people with fibro don't take narcotics to help the pain. I know this is a lie. He gave me topamax and upped my cymbalta.
Honestly, I have tried so hard not to take the pain pills even when I had them but the pain is just Soooo bad! I don't know what to do. Do I look for another doctor. Try to find alternate ways to get the medication I need? The 5/500 Lortab would barely take the edge off at times. What are people like me supposed to do?
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Anybody else have this symptom? Can't say I've ever had it before. Don't know if it's the fibro or something else. Just hoping to get some input. For women with children, the pain reminds me of being 8 or 9 months pregnant and the baby is pushing out on your ribs! Make sense? TIA!
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any ideas out there on what actually works for the severe fatigue that comes day after day?. i heard provigil would be really good,but no insurance will cover it,so no doctor will even prescribe it.anyone get prescribed phentermine? ive tried adderall,it made me twice as tired, and ritalin worked for awile,but makes me tired as well.any ideas??im not talking a little bit of fatigue,its severe,that days i feel like i just cant go on at all.i have a hyper son diagnosed with autistic/sprectrum disorder,so i have to keep up with him.
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"(1) Fibromyalgia is a set of symptoms and signs resulting from hypometabolism. (2) Most patients’ hypometabolism has multiple causes. (3) The most common and most potent cause of patients’ hypometabolism is too little thyroid hormone regulation, due either to hypothyroidism or partial cellular resistance to thyroid hormone."
T4 and T3 levels are directly linked to almost every aspect and symptom of fibro, overseas and even in the united states it is becoming more clear that hypothyroidism could be the culprit of fibromyalgia. symptoms of hypothyroidism are:
Note symptoms including: weight gain, depression, forgetfulness, fatigue, hoarseness, high cholesterol, constipation, feeling cold, hair loss, dry skin, low sex drive, tingling hands/feet, irregular periods, infertility.
Note related conditions, including: recurrent pregnancy loss, resistant high cholesterol, difficult menopause, fibromyalgia, chronic fatigue syndrome, carpal tunnel syndrome, mitral valve prolapse.
This is from many different studies and is fact.
My suggestion is to read the following links i post here and go see an endocrinologist to have your TSH T3 T4 Free T3 and Free T4 levels checked. some may come back looking fairly normal and in this case have him run a TRH stimulus test (Thyrotropin-releasing hormone), that is explained in this link: http://www.rain-tree.com/fibromyalgia.htm
also please trust me and read these links below to determine if you should look into hypothyroidism.
http://www.ei-resource.org/illness-information/related-conditions/thyroid-treatments/
http://www.drlowe.com/frf/england2002/brief.htm
i hope this helps.
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