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					Chronic Fatigue Syndrome/Fibromyalgia Similarities-Differences-Overlap
Kenneth J. Friedman, Ph.D. Associate Professor of Pharmacology and Physiology New Jersey Medical School Newark, NJ 07103

Prepared for the Everglades AHEC

April 11, 2008
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Disclosures for Dr. Friedman
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New Jersey Chronic Fatigue Syndrome Association: Board Member and Chair of

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Medical Student Scholarship Committee P.A.N.D.O.R.A.: Secretary, and Chairman of Public Policy Committee Vermont CFIDS Association: Member Consultant to MedaCorp: provide advice and expertise to unknown clients Consultant to Hemispherex: limited to public policy not drug development
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Part I:
Chronic Fatigue Syndrome

CFS Case Definition and Criteria
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A CFS patient must have:
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Persistent or relapsing fatigue of 6 months or longer duration Fatigue severity significant enough to greatly reduce activities of daily living All other known medical conditions excluded by clinical diagnosis

CFS Case Definition and Criteria
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All of the above and concurrently have four or more of the following eight symptoms:
•Post-exertional malaise lasting more than 24 hours
•Unrefreshing sleep •Impaired memory and concentration •Muscle pain •Multi-joint pain without redness or swelling •Headache of a new type or severity •Sore throat •Tender cervical or axilliary lymph nodes

Political History of CFS
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CFS was formally defined in 1988
CFS is known by other names: CFIDS, ME, Myalgic Encephalitis, Myalgic Encephalopathy, ME/CFS, CFS/ME Comparable illnesses have been documented for centuries

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Cause/Contributing Factors of CFS
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The cause of CFS is unknown. Epstein Barr Virus was at one time thought to be the cause. Research has shown this to be false:
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EBV appears to be precipitate/trigger CFS in some patients. Not all CFS patients have or had EBV

Possible Contributing Factors
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Infectious agents Immune System Dysfunction Sleep disorders

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Dysautonomias Neuroendocrine Dysfunction Other possible causes

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Current theories:
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Multiple factors may be involved Final common pathway

What is CFS?
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Is CFS…
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a syndrome?

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a disease?
an illness? a disorder?

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Myths
Facts
Because of the controversial nature of CFS, a number of myths surround it. Three of the most common myths are:

vs.

Fact or Myth?
CFS is a relatively rare disorder.

MYTH !

CFS Prevalence
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CFS affects approximately 200-500 per 100,000 adults An estimated 18% of those classified as having CFS have been diagnosed by a health care professional (CDC)

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Fact or Myth?
The highest prevalence of CFS is among middle-aged, affluent, white, professional women.

MYTH !

CFS Prevalence
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CFS is most common among women between 40-54 years of age CFS is at least as common among black and Hispanics as among white women Persons of middle-income status are at the greatest risk

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CFS Prevalence
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Race  All races need to be carefully evaluated

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Gender  Women have a much higher rate of CFS than men: A ratio of 3:1

CFS in the Pediatric/Adolescent Population
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Limited data on this population.

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Pediatric/adolescent CFS prevalent rate appears to be lower rate than in adults.
Newly published pediatric/adolescent CFS case definition relaxes some of the more stringent adult criteria.

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Fact or Myth?
CFS is a form of depression.

MYTH !

CFS and Depression
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CFS and Major Depressive Disorder (MDD) have many symptoms in common. Both can be overlooked easily.
Careful evaluation is required.

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CFS and Depression

Depression is an illness that MUST be diagnosed and treated.

Differentiating CFS from Depression
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Depressed patients are capable of physical activity but lack the motivation.
CFS patients have the motivation for physical activity but lack the capability.

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Diagnosis of CFS

The diagnosis of CFS is primarily one of EXCLUSION

Diagnostic Procedure for CFS Fatigue

Symptom Driven Evaluation: 1.History & Physical findings 2.Psychological and Neurological examination 3.Exclusionary lab tests

Diagnostic Procedure for CFS

Meets ≥ 4 of the 8 Symptom Criteria:
1. impaired memory or concentration
2. sore throat
3. Tender cervical or axillary lymph nodes 4. muscle pain 5. Multi-joint pain 6. New headaches 7. Unrefreshing sleep 8. Post-exertional malaise

No Plausible Explanation

Diagnostic Procedure for CFS
No Plausible Explanation

Chronic Fatigue ≥ 6 months
Significantly affects daily activities and work

Chronic Fatigue ≤ 6 months
•Provide appropriate treatment •Reevaluate at appropriate intervals

No significant impact

Diagnostic Procedure for CFS

Satisfies 4 or more of the 8 secondary CFS criteria

Diagnosis of CFS
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Diagnostic Procedure for CFS
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See Appendix for:
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Unique aspects of medical history and physical examination of CFS patients. Recommended laboratory tests and additional testing.

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Diagnostic Challenges 1
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Patients with CFS often have a relatively normal physical examination

 A diagnosis of CFS cannot be made without a proper psychological evaluation

Diagnostic Challenges 2
There are plausible explanations of fatigue that preclude a CFS Diagnosis
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Narcolepsy Sleep Apnea

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Chronic active hepatitis B or C Hypothyroidism

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Iatrogenic: e.g. medication side effects.

Diagnostic Challenges 3 Conditions with Chronic Fatigue Symptoms
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Lupus erythematosus

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Severe obesity

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Lyme disease
Multiple sclerosis Rheumatoid arthritis

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Tuberculosis
Nutritional deficiency, e.g., fad diets, supplement use

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Diagnostic Challenges 4
Psychological Issues
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Several psychological illnesses resemble CFS and are exclusionary for CFS Exclusionary psychological conditions listed in appendix.

Diagnostic Challenges 5 Abnormal Patient Reports and Behavior
 Psychomotor

slowing  Cognitive impairment  Odd interpersonal behaviors  Angry, hostile responses  Suicide risk assessment

Diagnostic Challenges 6 Autonomic Dysfunction
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Common in a subset of CFS patients
Rule out types of orthostatic intolerance Tilt-table testing may be indicated for some patients with appropriate symptom profile

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Diagnostic Challenges 7 The Presence of Fibromyalgia
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Fibromyalgia may co-exist with CFS
Emphasis on musculoskeletal pain rather than fatigue Fibromyalgia will be discussed in Part II of this presentation.

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Conditions with Overlapping Symptoms
TMJD OAB Pelvic Pain

CFS
IBS MCS

GWI/S

MVP

Intermission

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CFS Management
The goal is to:  assist patients to return to as normal function as possible  maximize well-being  set and maintain realistic expectations  See appendix for management goals and strategies

Prognosis


No long term prognosis can be made
Lack of treatment may negatively impact prognosis The primary care provider can help to improve quality of life for people with CFS

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Disability and CFS
 All patients with CFS are impaired and many suffer occupational disability
 Application process is protracted and frustrating  The Primary Care Provider is a major source of documentation for disability benefits

Impact


CFS has a significant impact on society, individually and collectively
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The hardship on individuals is incalculable The economic impact alone is estimated to be over $8.8 billion per year Research and education efforts are ongoing

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Conclusion

The goal of primary care providers is to help the patient reach an improved level of functioning.

Part II: Fibromyalgia

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Fibromyalgia Syndrome (FM or FMS)
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A syndrome characterized by widespread muscle pain, fatigue and multiple tender points. Tender points- specific places on the body – neck, shoulders, back, hips, and extremities- where patients feel pain in response to slight pressure. FMS is a chronic condition.
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Fibromyalgia Syndrome
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80 % of patients are women Most commonly affects patients aged 3555 years of age. Affects 3 – 6 million Americans. The pain and fatigue of FMS can interfere with the ability to carry on daily activities.

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Symptoms of FMS 1

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Pain throughout the body and a feeling of fatigue. Muscles affected are in shoulders, buttocks, neck and lower back. Pain seems to originate tender points.

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Symptoms of FMS 2
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Pain exacerbated by stress, weather changes, loud noises and anxiety. Symptoms range from mild to severe. Symptoms may be intermittent.

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Specific Symptoms of FMS 1
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Sleep disturbances (which may add to the feeling of fatigue). Morning stiffness. Numbness or tingling of extremities. Restless leg syndrome. Temperature sensitivity. Cognitive and memory problems (Fibro fog). Painful menstrual periods.
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Specific Symptoms of FMS 2
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Headaches and jaw pain. Sensitivity to odors, bright light, noise, food, changes in weather, and medicines. Gastrointestinal problems: IBS, diarrhea, constipation, heartburn and difficulty swallowing. Women way have pelvic pain, painful sexual intercourse Frequent urination, strong urge to urinate, pain in the bladder.
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Cause
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Cause is unknown.

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Possible Causes of FMS
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Possible causes include:  Imbalance of CSF substances  Neurotransmitter imbalance in the brain  Low level of serotonin  Abnormal sleep – lack of non-REM  Stress  Infections  Injuries  Inherited genetic tendency – runs in families
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Co-morbid conditions
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FMS commonly seen in patients with:
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Rheumatoid arthritis Lupus

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Diagnosis of FMS 1
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Dx of FMS is given only after other muscle, joint and gland diseases with similar symptoms have been ruled out. Detailed medical history and physical exam. Blood tests and radiological tests performed to exclude other illnesses with similar presentations.

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Diagnosis of FMS 2
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There is no diagnostic test for FMS There is no object test for FMS Patients often accused of faking or imagining symptoms. Dx best made on the established criteria of the American Academy of Rheumatology (ACR).

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ACR Criteria for FMS
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A history of widespread pain lasting more than 3 months and the presence of tender points. Pain affects all 4 quadrants of the body- right and left sides, above and below the waist. Pain must be present at 11 or more of the 18 FMS tenderpoints. A designated site is a tender point if a force of 4 kg results in pain.

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Treatment of FMS -1
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Goal: Manage the symptoms of FMS Strategy: Assemble a treatment team  Physician(s)  Physical therapist  Other healthcare professionals  Massage therapist  Psychotherapist  Patient participation

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Treatment of FMS 2
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Pharmaceuticals –
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Analgesics – prescribed for muscle pain Antidepressant medications

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Benzodiazepines – tranquilizer with hypnotic, sedative properties Complimentary and Alternative medicine treatments (see Appendix for examples)

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Self-Care for FMS 1
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A healthy living program  Reduce stress – avoid stressful situations  Sleep well – good sleep hygiene; avoid caffeine and alcohol, use a comfortable mattress  Exercise regularly – stretch upon waking; low impact exercise. Try to maintain body weight.
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Self-Care for FMS 2
Eat a healthy diet – avoid alcohol, caffeine, candy, known foods that cause allergic reactions  Manage symptoms – treat symptoms as they arise  Maintain social contacts – social stimulation prevents often accompanying depression.
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Summary
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FMS is a syndrome that causes pain and fatigue in muscles, joints, ligaments and tendons. There is no cure for FMS. Treatment of FMS includes:  Medication  Improvement of general health through self-care.  Complimentary and Alternative Medicine  Stress Management
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Comparison of CFS and FMS 1
CFS
Type of Disorder Syndrome Illness 1 million 3:1 Case Definition Dx of exclusion

FMS
Syndrome Illness 3-6 million 4:1 Tender Points Dx of exclusion
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Prevalence
Women:Men Diagnosis

Comparison of CFS and FMS 2
CFS
Major symptoms Goal of Treatment Prognosis Chronic fatigue; non-restorative sleep Manage symptoms Life-long disability

FMS
Chronic pain; tender points Manage symptoms Life-long disability
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The End!
Questions?

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Appendix
Supplemental Information for Lecture

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The Medical History & Physical Exam of a CFS Patient
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MH and PE are almost always more lengthy than the allotted time period for a „routine‟ MH and PE Office visits of a CFS patient require more time than office visits of most other patients.

Suggested Lab Tests for the CFS Patient 1
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Urinalysis Complete blood count with leukocyte differential Erythrocyte sedimentation rate or C reactive protein Alanine aminotransferase or aspartate transminase serum level Albumin

Suggested Lab Tests for the CFS Patient 2
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Globulin Alkaline phosphatase Glucose Calcium Phosphorus Thyroid function test (TSH and Free T4) Rheumatoid factor (if arthritic complaints are present)

Diagnostic Procedure for CFS
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Additional Testing
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EBV titer Tilt table Sleep studies Other tests as indicated by patient history and physical exam.

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Psychological Conditions That Preclude a Dx of CFS
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Bipolar disorder Schizophrenia Dementia Psychotic or melancholic depression Anorexia nervosa Bulimia nervosa Active alcohol or substance abuse (current or within preceding two years)

CFS Management 1


Provide the patient with general information about the nature of the illness brochures, materials, etc.  Resource contact information
 Educational

CFS Management 2
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Develop an individualized plan
 Supportive  Symptomatic

CFS Management 3 Supportive Treatment
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Diet  Optimal, well-balanced diet  Weight management issues  Referral to registered dietitian

CFS Management 4 Supportive Treatment
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Activity  Highly individualized  Paced; avoid overexertion; find the correct balance to prevent “boom or bust” cycles  Referral to physical or occupational therapist

CFS Management 5 Supportive Treatment
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Coping skills  Counseling  Cognitive behavioral therapy (CBT)  Although not a cure for CFS, it can help improve function and coping abilities

CFS Management 6 Symptomatic Treatment
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Although there is no cure for CFS, patients can be helped. Address the symptoms and tailor a management plan accordingly.

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CFS Management 7 Symptomatic Treatment
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Sleep Disturbances  Establish normal sleep hygiene
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Limit pharmacological agents Explain why limit is necessary Refer patients to a sleep specialist

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CFS Management 8 Symptomatic Treatment
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Cognitive Dysfunction  Cognitive training is highly specialized form of therapy and requires referral to a trained clinician

CFS Management 9 Symptomatic Treatment
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Depression  Commonly accompanies CFS and must be treated
 Psychological

screening instruments

CFS Management 10 Symptomatic Treatment
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Pain  Simple analgesics  acetaminophen, aspirin or NSAIDs
 Non-pharmacological

modalities  paced activity, gentle massage, physical therapy, TENS units, cool or hot packs

CFS Management 11 Symptomatic Treatment
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Pain  Pain management counseling
 Referral

to a pain management specialist  Narcotics are not recommended except in consultation with pain management specialists

CFS Management 12 Symptomatic Treatment
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Dysautonomias  Increased fluid and salt intake
 Compression

garments

 Referral

to a neurologist or cardiovascular specialist for pharmacological therapy with such drugs as fludrocortisone, midodrine, beta-blockers or alpha agonists

CFS Management 13 Symptomatic Treatment
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Other conditions  IBS
 Fibromyalgia

 TMJD

 Overactive

bladder

CFS Management 14 Symptomatic Treatment


Other conditions  Pelvic pain
 Pain

syndrome
chemical sensitivities

 Multiple  Mitral

valve prolapse

Complementary & Alternative Medicine (CAM)Treatments for FMS 1
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Physical and occupational therapy. Learn pain management techniques Learn coping techniques (Cognitive Behavioral Therapy – CBT) Massage

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Complementary & Alternative Medicine (CAM)Treatments for FMS 2
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Movement therapies – Pilates, Feldenkrais methods Chiropractic treatments Acupuncture Herbs and dietary supplements  There is little scientific proof that herbs or dietary supplements are of benefit.
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CAM Treatments for FMS Massage Therapy
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Choice of therapies – Swedish, Deep (Connective) Tissue, Shiatsu Possible benefits include:  Increased blood circulation  Loosening of sore muscles  Increased flow of nutrients to muscles  Removal of “toxins” from muscles  Alignment of muscles and joints  Relieves stress and anxiety

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CAM Treatments for FMS Acupuncture/Acupressure
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Accupressure – application of pressure via practitioner‟s fingers at specific points on the body to increase the flow of energy through disrupted pathways. Accupressure – insertion of small needles at acertain points of the body to restore energy flow through disrupted pathways.

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CAM Treatments for FMS Trigger Point Therapy/Chiropractic Care
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Trigger Point Therapy – application of pressure for a few minutes at/on specific trigger points (points at which muscle pain originates). Chiropractic Care – realignment of vertebrae of the spine. Vertebrae are stretched to relieve pressure on nerves.

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