Fibromyalgia

Fibromyalgia is a common and complex condition marked by diffuse pain in muscles, joints, ligaments and tendons, feeling tired and stiff, trouble sleeping and feeling depressed. The symptoms of fibromyalgia are a little different in every person who has it. There are no cures and treatment is frustrating to not only the sufferers but also to physicians. Because of all the effects of magnetic fields on the body and the lack of side effects, PEMFs are very useful in this condition, and the commonly related conditions, especially those devices that have  brain frequency settings.

The fundamental cause of fibromyalgia is unknown. Many theories exist which contributes to the lack of a definitive successful conventional therapy. Not sleeping well and not exercising are associated with it. Significant sudden or more moderate chronic stress (such as having and caring for a new baby) or recurrent poor sleep may cause fibromyalgia in people who are more pre-disposed to be more sensitive to pain. Characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters suggest that imbalance of the autonomic and neuroendocrine system may be at the root. Many people have had physical and psychologic trauma before the onset. The sleep electroencephalogram (EEG) shows disturbance of the non-REM sleep phase by intrusions of alpha waves with little deep (stage 3 and stage 4) sleep.  People report awakening repeatedly and being “un-refreshed by sleep.”  Each of the stages of sleep have special hormone release activity. For example, release of growth hormone occurs primarily during stage 3 and stage 4 of non-REM sleep. One third of sufferers have low insulin growth factor (IGF) levels, an indication of low growth hormone secretion. Symptoms of fibromyalgia may be created or worsened by disturbing non-REM sleep. The knowledge in this condition is constantly changing.

Other Findings
Other endocrinologic and neurologic findings in patients with fibromyalgia include:

• Brain substance P levels (a neurotransmitter associated with enhanced pain perception) increase to three times normal.
• There is low overall cortisol, the opposite of depression, where higher-than-normal cortisol is found.
• Symptoms are induced during tilt table testing with drops in blood pressure.

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How would I know I have fibromyalgia?

You always hurt in many places but, frustratingly, tests come back normal.  No laboratory or radiology tests can prove you have fibromyalgia. The diagnosis is likely when the symptoms you have fit the right pattern, but no other problems are found. When your doctor examines you, you’ll have many “tender points” where your skin hurts even if you barely touch it. Common tender points are at the front of the knees and elbows, the hip joints and around the neck. Making the diagnosis of fibromyalgia depends on the history and physical examination rather than on diagnostic testing.

In 1990, the American College of Rheumatology (ACR) established criteria for classifying patients with fibromyalgia. Failure to meet these criteria does not absolutely exclude the possibility of fibromyalgia. The introduction of the ACR fibromyalgia classification criteria 20 years ago began an era of increased recognition of the condition. The criteria were difficult to use. Since fibromyalgia diagnosis has become a symptom-based diagnosis. Other symptoms have become key fibromyalgia features: fatigue, cognitive symptoms, and extent of somatic symptoms. The original ACR criteria missed the diagnosis in a lot of people. As a result in May 2010 new criteria have been recommended. These new criteria consider the severity of symptoms.

Criteria

A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:

1) Widespread pain index (WPI) >7 and symptom severity (SS) scale score >5 or WPI 3–6 and SS scale score >9.

2) Symptoms have been present at a similar level for at least 3 months.

3) The patient does not have a disorder that would otherwise explain the pain.

Work-up

1) WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain?

 

Left -  Jaw, Neck, Shoulder girdle, Upper arm, Lower arm, Chest, Upper back, Lower back, Hip (buttock, trochanter), Upper leg, Lower leg 

Right – Jaw, Neck, Shoulder girdle, Upper arm, Lower arm, Chest, Upper back, Lower back, Hip (buttock, trochanter), Upper leg, Lower leg

Score will be between 0 and 19.

2) SS scale score: Fatigue, Waking unrefreshed, Cognitive symptoms

For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale:

0 . no problem

1 . slight or mild problems, generally mild or intermittent

2 . moderate, considerable problems, often present and/or at a moderate level

3 . severe: pervasive, continuous, life-disturbing problems

Considering somatic symptoms in general, indicate whether the patient has:*

0 . no symptoms

1 . few symptoms

2 . a moderate number of symptoms

3 . a great deal of symptoms

The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

As a result using the combined SS scale and the WPI, the new definition of fibromyalgia is: (WPI >7 and SS>5) or (WPI 3-6 and SS>9)

* Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

See: American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity   http://www.rheumatology.org/practice/clinical/classification/fibromyalgia/2010_preliminary_diagnostic_criteria.pdf

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The diagnosis may still be established using the 1990 criteria, but the new criteria will allow more people to be diagnosed.

As with other rheumatologic disorders, fibromyalgia:

• Is established on the basis of clinical observations.
• Is a condition with signs and symptoms that exist across a spectrum – not having all of them doesn’t mean you don’t have the condition.
• Often requires observation over time to firmly establish the diagnosis.

FIGURE 1. Locations of standardized tender points of fibromyalgia. Criteria for classification of fibromyalgia: pain on palpation with a 4-kg force (Pain at 11 of 18 sites is necessary to meet the criteria.).

 

 

American College of Rheumatology Criteria for Classification of Fibromyalgia
Widespread pain for at least three months, defined as the presence of all of the following:

• Pain on the right and left sides of the body.
• Pain above and below the waist (including shoulder and buttock pain).
• Pain in the axial skeleton (cervical, thoracic or lumbar spine, or anterior chest).

Pain on palpation with a 4-kg force in 11 of the following 18 sites (nine bilateral sites, for a total of 18 sites):

• Occiput: at the insertions of one or more of the following muscles trapezius, sternocleidomastoid, splenius capitus, semispinalis capitus.
• Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5-C7.
• Trapezius: at the midpoint of the upper border.
• Supraspinatus: above the scapular spine near the medial border.
• Second rib: just lateral to the second costochondral junctions.
• Lateral epicondyle: 2 cm distal to the lateral epicondyle.
• Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscle.
• Greater trochanter: posterior to the greater trochanteric prominence.
• Knee: at the medial fat pad proximal to the joint line

Other possible conditions that can look like fibromyalgia
The diagnosis may be made based on the ACR criteria or on the presence of the characteristic syndrome, or both. A minimum of tests need to be done when someone looks obvious. The thyroid-stimulating hormone level should be checked routinely because hypothyroidism can mimic the symptoms of fibromyalgia. Other diagnoses to consider include drug-induced muscle problems (especially those from statin drugs), polymyalgia rheumatica and other rheumatologic syndromes.

Myofascial pain syndrome may be confused with fibromyalgia and may be seen in patients with fibromyalgia. Myofascial pain syndrome is also mostly diagnosed clinically. While the pain of fibromyalgia is widespread with changing areas of emphasis, myofascial pain arises from trigger points in individual muscles. The pain pattern is limited to a particular region over time. Fatigue is less likely to be as great.

Myofascial pain syndrome is based on having trigger points vs tender points. Trigger points and tender points are often in similar locations. Trigger points are found in taut bands of muscle, whereas tender points are not. Pressing on trigger points often reproduces the pain radiation pattern and can cause a twitch in the muscle. The pain from pressing on a tender point is local to the area under palpation and does not elicit a jump or twitch. Also, trigger points often have a lumpy or dough-like texture similar to a pencil eraser, whereas tender points are no different from surrounding tissue.

Related Conditions
Patients with fibromyalgia often have one or more related conditions:

• Migraine headache
• Chronic fatigue
• Irritable bowel syndrome
• Depression
• Restless legs syndrome
• Temporomandibular joint (TMJ) syndrome
• Myofascial pain syndrome

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How is fibromyalgia typically treated?

Improving sleep is key and reducing your pain. Good nutrition and exercise often help. Exercise should be low-impact aerobic exercise like swimming or stationary bicycling. Exercise might make your pain worse at first. If you do it regularly, though, it usually helps. Try not to exercise too hard. If you do too much on days that you feel good, you might end up feeling worse. Keeping up the exercise is vital though. Support groups or behavioral therapy or counseling may be needed too.

Because the symptoms of fibromyalgia wax and wane, treatment (as with that of other chronic conditions) is an ongoing process versus a single episode. Flare-ups often worsen any underlying stress. Stress, even day-to-day hassles, can cause flare-ups. Treatment approaches need to be individualized as not all individuals show the same response to any given program.

Other treatments can be tried: acupuncture, massage and physical therapy, cranial electrical stimulation using the Fisher-Wallace machine (formerly the Liss Machine), relaxation response training and movement therapy, training in coping skills and/or chiropractic. In some people hypnosis can improve functioning and reduce pain more than physical therapy.

Removal of Exacerbating Factors
Eliminate consumption of stress, coffee, smoking, and alcohol. Worsening factors include improper body mechanics at work or play, flat feet and anxiety.

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How can magnetic field treatment help with fibromyalgia?

Treatment Goals:

• Maintaining good health is basic.
• Whole body balancing is key to regulate the sympathetic and parasympathetic or autonomic nervous system balance. Imbalance here is a major contributor to feeling stressed.
• Control pain and improve energy, sleep, rest, capacity for recovery and overall function.
• Attempt to reduce the cause/s.
• Daily use.
• Stress reduction.
• Blocking electrosmog.
• Reduce dependence on medications.

The basic actions of magnetic fields that can help fibromyalgia:

• reducing muscle tension
• improving circulation
• reducing pain
• stimulating the immune system
• improving cell function
• helping the body to detoxify
• improving the uptake of nutrients
• helping nerve function
• helping liver function
• balancing the acupuncture meridians
• improving sleep
• reducing stress
• balancing the endocrine system
• reducing trigger point tenderness

Taken together all these actions of magnetic fields help the body stay well and rebalance problems before they will ever become noticeable by you at the cellular level, the physiologic level and the emotional level.

Balancing actions of magnetic fields
All these actions of magnetic fields happen at the same time. The ones that get turned on depend on what the body needs at the time. They are not specifically “tunable.”  That means you can’t decide which ones will be activated at any given time. They are all potentially active all the time. If the body is healthy and balanced for any given action, will not be seen. That means you won’t notice that particular effect. The body will decide what it needs. This is the beauty of magnetic therapies – they will work with the body’s own systems. In this respect they act like acupuncture therapy. They only act to stimulate the body’s own systems. They will not create actions the body isn’t capable of. The actions of the PEMFs I recommend are natural in the body.

Actions depend on field characteristics
What will determine what actions happen in the body is dependant on the characteristics of the magnetic system used. These include:

• the types of frequencies,
• the strength/s of the field,
• size of the magnetic field,
• the time it is used for and
• how often it is used for.

For fibromyalgia the best effects would happen with:

• whole body exposures,
• daily use and
• low intensity ELFs
• cranial electrical stimulation with the Fisher-Wallace machine

Small area ELF devices, that you may already own, can help the overall body as well, from the treatment of any local problem. But, this whole body reflex action is incidental and not as effective for fibromyalgia as whole body treatment.

Static Magnets

Static magnetic mattresses can be helpful (although sometimes irritating) but whole body pulsed fields are better. Also the pulsed fields tend to be more flexible and offer multiple uses for the same cost. They may cost more initially but are a better health investment in the long run and may be better if myofascial pain or one of the associated conditions is present.

Small permanent magnets, used on acupuncture points or tender/trigger points may also be helpful for health maintenance but you have to know where to put them. These can sometimes be useful to wear during the day over the worst tender or painful spots. Using them over acupressure points is one way to start. An acupressure book that could be helpful to locate and use these points is Acupressure’s Potent Points: A Guide to Self-Care for Common Ailments. Some of these points may be helpful for anxiety or depressive symptoms too.  The Large Intestine 4 point, Spleen 6 or Stomach 36 can help especially.  Pressure massage over GV 24.5 and GV 20 are very helpful and a handheld tens/acupoint stimulator can be used to stimulate several ear acupoints (zero point and shen men) as well as GV24.5 and GV20. Even so, whole body balancing, by using whole body treatments takes away the guesswork of which points to use at any given time.

Various kinds of magnets may be combined depending on where the tender/trigger points are. The size of the magnet, will depend on the area needing treatment.

• Back of head: acupuncture magnets, large neodymiums, magnetic collars, head band or necklace
• Neck: acupuncture magnets, large neodymiums, flexible wraps or discs, magnetic, head band or necklace
• Shoulders: acupuncture magnets, large neodymiums, flexible wraps or discs, magnetic, head band or necklace
• Ribs: acupuncture magnets, large neodymiums, flexible wraps or discs
• Elbow: acupuncture magnets, large neodymiums, flexible elbow wraps or discs, magnetic band or bracelet
• Buttocks: acupuncture magnets, large neodymiums, flexible wraps, discs or boards, even shoe inserts used over the pain or in the shoes
• Hips: acupuncture magnets, large neodymiums, flexible wraps, discs or boards, even shoe inserts used over the pain or in the shoes, or belts
• Knees: acupuncture magnets, large neodymiums, flexible wraps, discs or boards, even shoe inserts used over the pain or in the shoes

Remember not to use these all day long every day. I suggest giving the body a break for 8 or more hours each day to avoid tolerance happening. Of course, pain anywhere else can be treated with these as well. Permanent magnets can be used along with the PEMF systems. Remember also that permanent magnets can harm credit cards, tapes and should not be used with pacemakers, etc. See the contraindications section.

Research has shown benefit from using static magnetic mattresses for fibromyalgia. They may be used in combination with PEMF systems, so don’t throw away your magnetic mattress if you already like to use one. The two together should help even more. It may be worth experimenting to see how they work together or not, since every body is unique in it’s reactions.

Electrosmog
Electrosmog is a powerful energy drainer and strong stress inducer. People with Fibromyalgia, Chronic Fatigue and Chemical Sensitivity tend to also have electrical sensitivity. Electrosmog is important to control in individuals with fibromyalgia.

Electrosmog is pervasive and insidious. It is all around us – and goes right through us, all day, every day. Computer terminals, hair dryers, TVs, electric stoves, the wiring in the house and our cars, stereos, microwave antennas, wireless systems, all strongly act on our bodies. They can’t be blocked – anywhere on the planet. We can only decrease them or add frequencies to the body that balance the body. They throw off body systems continually – day and night. Cell phones are the newest “societal need.” They deliver very powerful effects to the brain and are like sticking your head in a microwave oven. As the brain goes, so goes the rest of the body.

See the discussion on the subject in the General Health section on mitigation.

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Specific magnetic field devices

I recommend any of the PEMF devices that offer whole body treatment over static magnetic devices, if a choice is available.

If there is a strong component of anxiety or depressive symptoms, I also suggest considering the Fisher  Wallace device for cranial electrical stimulation.

^{How to use PEMF devices for Fibromyalgia}
Since the recommended devices can have complicated set-ups and treatment regimens and often do not come with explicit directions, consultation is the best way to get individually tailored protocols, specific to any given individual’s unique overall health issues or needs.  Otherwise, the manufacturer’s directions can be a starting place.

Always check for sensitivity when you start. If you think you may be sensitive, or know you are, start low and go slow in advancing the settings.

In addition:

• Always treat your day’s water ration on the system with you in the morning – preferably in a glass container without a metal lid.
• Take your morning supplments before you get on the system. There are no supplements I know of no supplements that have to be avoided with these treatments.
• Have a drink of water – at least 10-16 ounces before you get on the system.
• Have your breakfast first to stimulate digestion.
• Let your body tell you what it needs in terms of settings, length of treatments and/or placements of applicators.
• Do what you can to to counteract the effects of electrosmog, so that the fatigue effects of this electro pollution won’t wear you down and create additional stress.
• You should strongly consider testing your home and workplace for electrosmog and then using filters to counteract this additional electrosmog effect. Home and workplace electrosmog is potent and pervasive. See the section on this ((((dirty electricity ))))).
• It doesn’t matter when supplements are taken relative to magnetic field therapy. In the ideal circumstance they should be taken about half an hour to one hour before the magnetics treatment.
• Key to success is daily use – twice a day if you can. In the morning to wake up the cells. In the evening to clean out the effects of the day’s stresses on the body. You can still use the system mid-day if needed for any other given problem/s. Health Maintenance settings may be combined at any given treatment session with treatment settings and pillow/pad placements as needed.

In the morning: if sensitive, start at the lowest setting and gradually- typically every 3-4 days -  increase the settings until the strongest setting is reached. If not sensitive, typically start the mid-range and increase the settings, by one or two every day until the strongest setting is reached. Once the highest setting is reached is reached, you can stay at that level or whatever level seem sto produce the best results from then on, unless you have a reaction or your intuition tells you another setting is preferred.

In the evening: you may need to use a lower intensity just before bedtime in case the body may become over stimulated and interfere with sleep. However this will be an individual consideration and you may have to try different intensities to find what works best for you, balancing symptom reduction and achieving sleep. You may also find that you may use stronger intensities before bedtime for a short period of time for arthritis symptom management followed by other frequency or intensity settings that may enhance sleep.

Go to my Product Reviews for more information on specific magnetic field devices.

Conventional Treatment of Fibromyalgia

Treatment is by trial and error. Experience and small clinical studies have found some benefit from low-dose antidepressant therapy, cyclobenzaprine (Flexeril) and/or exercise. Anti-depressants are commonly used. But, a significant portion of patients on anti-depressants find their symptoms may worsen.

Lyrica has been approved for fibromyalgia. It is not at all a panacea. 48% of placebo patients responded vs 66-77% for Lyrica. That’s an 18-29% margin of benefit. Five people have to be treated for one to get a benefit. The benefit also drops off by about 40% in 2 months. There appears to be a slightlyhigher benefit with the higher dose, but the risk of side effects increases too. 53% of the Lyrica-treated patients compared to 33% of placebo patients remained on the treatment and maintained a therapeutic response for 6 months. When Lyrica is the only treatment option, it is worth considering. However, PEMFs can produce an even better response, with or without Lyrica. I have seen that the benefits of Lyrica along with PEMFs can be better with a lower dose, when both were combined.

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Nutritional recommendations

Go to…

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References

Fibromyalgia Resources: www.arthritis.org, www.fmnetnews.com

Most resources are very conservative because of their medica advisors and do not recommend complementary approaches as much as they should. Cranial electrical stimulation and magnetic therapies are mostly unknown by them. They are given here for completeness.

Stress review paper

• Alfano, AP, Taylor , AG, Foresman , PA ,Dunkl, PR, McConnell, GG, Conaway, MR, Gillies, GT.
• Static magnetic fields for treatment of fibromyalgia:  a randomized controlled trial. J Altern Complement Med 7(1):53-64, 2001.
• Brown, C.; Ling, F.; Wan, J.; Pilla, A. Non-invasive static magnetic field therapy reduces chronic pelvic pain:  a double-blind pilot clinical study. Bioelectromagnetics Society, 24th Annual Meeting, 23-27 June, Quebec City, QC, Canada, Abstract No. 8-3, p. 49-50, 2002.
• Colbert, A P, Taylor, AG, Foresman , PA , Conaway, MR, Alfano, AP. Magnetic-field studies encouraging – discussion of magnetic sleep pad study (letter and reply).  J Altern Complement Med 7(5):393-399, 2001.
• Colbert, AP, Markov , MS , Banerji, M, Pilla, AA. Magnetic mattress pad use in patients with fibromyalgia:  a randomized double-blind pilot study. J Back Musculoskeletal Rehabil 13(1):19-31, 1999.
• Goldenberg DL. Fibromyalgia, chronic fatigue syndrome, and myofascial pain syndrome. Curr Opin Rheumatol. 1995 Mar;7(2):127-35.
• Hausotter, W. Modern illnesses from the critical viewpoint. Versicherungsmedizin 53(4):177-181, 2001.
• Janssens LA. Trigger point therapy. Probl Vet Med. 1992 Mar;4(1):117-24.
• Khramov, RN, Vorobiov, VV, Yarkov, AV. Difference in the effects of millimeter radiation by rats in norm and after a pain stress caused by electric stimulation.  Fundamental and Applied Aspects of the Use of Millimeter Electromagnetic Radiation in Medicine.  Abstracts of the 1st All-Union Symposium with International Participation.  10-13 May, 1989, Kiev , Ukraine , p. 155, 1989.
• Lautenbacher, S. The role of pain perception in the etiology of chronic pain and the causation of sex differences. Bioelectromagnetics Society, 24th Annual Meeting, 23-27 June, Quebec City , QC , Canada , p. 39, 2002.
• McCray, RE, Patton , NJ . Pain relief at trigger points:  a comparison of moist heat and shortwave diathermy. J Orthop Sports Phys Ther 5(4):175-178, 1984.
• Miriutova NF, Levitskii EF, Abdulkina NG. Electromagnetic and mechanical vibrations in the therapy of myofascial pains. Vopr Kurortol Fizioter Lech Fiz Kult. 2000 Jan-Feb;(1):14-6.
• Panagos A, Jensen M, Cardenas DD. Treatment of myofascial shoulder pain in the spinal cord injured population using static magnetic fields: a case series. J Spinal Cord Med. 2004;27(2):138-42.
• Pilla, AA. Static magnetic field therapeutics:  state of the art. Bioelectromagnetics Society, 23rd Annual Meeting, 11-14 June, St. Paul , MN , Abstract No. P-71, p. 159-160, 2001.
• Rauscher, E, Van Bise, WL. Pulsed magnetic field treatment of chronic back pain. Bioelectromagnetics Society, 23rd Annual Meeting, 11-14 June, St. Paul, MN, Abstract No. 10-3, p. 56-57, 2001.
• Sandstrom, M, Hansson Mild, K, Lyskov, K, Wilen, J, Bergdah, J, Eriksson, N, Hoog, J, Marqvardsen, I,  Marqvardsen, O, Stenberg, B, Widman, L. Electrical hypersensitivity – a multidisciplinary study.
• European Bioelectromagnetics Assoc. (EBEA), 4th International Congress, 19-21 November, Zagreb , Croatia , 1998.
• Smania N, Corato E, Fiaschi A, Pietropoli P, Aglioti SM, Tinazzi M. Therapeutic effects of peripheral repetitive magnetic stimulation on myofascial pain syndrome. Clin Neurophysiol. 2003 Feb;114(2):350-8.
• Thomas, AW, White, KP, Drost, DJ, Cook, CM, Prato , FS. A comparison of rheumatoid arthritis and fibromyalgia patients and healthy controls exposed to a pulsed (200 ut) magnetic field:  effects on norma l standing balance. Neurosci Lett 309(1):17-20, 2001.
• Vallbona, C, Hazlewood, CF, Jurida, G. Response of pain to static magnetic fields in postpolio patients:  a double-blind pilot study. Arch Phys Med Rehabil 78(11):1200-1203, 1997.
• Vallbona C, Richards T. Evolution of magnetic therapy from alternative to traditional medicine.  Phys Med Rehabil Clin N Am. 1999 Aug;10(3):729-54.
• Weintraub, MI, Vallbona, C, Hazlewood, CF. Magnetotherapy:  a new intervention? (letter and reply).
• Arch Phys Med Rehabil 79(4):469-470, 1998.
• Other Fibromyalgia references – no abstracts provided
• Berman BM, Ezzo J, Hadhazy V, Swyers JP. Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract 1999;48:213-8.
• Blunt KL, Rajwani MH, Guerriero RC. The effectiveness of chiropractic management of fibromyalgia patients: a pilot study. J Manipulative Physiol Ther 1997;20:389-99.
• Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. J Rheumatol 1991;18:72-5.
• Harding SM. Sleep in fibromyalgia patients: subjective and objective findings. Am J Med Sci 1998; 315:367-76.
• Keel PJ, Bodoky C, Gerhard U, Muller W. Comparison of integrated group therapy and group relaxation training for fibromyalgia. Clin J Pain 1998;14:232-8.
• Moldofsky H. Sleep and fibrositis syndrome. Rheum Dis Clin North Am 1989;15(1):91-103.
• Pillemer SR, Bradley LA, Crofford LJ, Moldofsky H, Chrousos GP. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum 1997;40:1928-39.
• Sandstrom MJ, Keefe FJ. Self-management of fibromyalgia: the role of formal coping skills training and physical exercise training programs. Arthritis Care Res 1998;11:432-47.
• Schneider MJ. Tender points/fibromyalgia vs. trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis. J Manipulative Physiol Ther 1995;18:398-406.
• Singh BB, Berman BM, Hadhazy VA, Creamer P. A pilot study of cognitive behavioral therapy in fibromyalgia. Altern Ther Health Med 1998;4:67-70.
• Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol 1996;25:77-86.
• Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-72.