When Mary Shomon’s doctor touched her, she cringed in pain. “I asked my doctor to check my fibromyalgia trigger points, and sure enough, I had pain levels that went through the roof at nearly every single spot she tested,” says the suburban Washington, D.C. resident. After suffering through bouts of chronic fatigue syndrome, chronic Epstein-Barr virus, two rear-end car crashes, and whiplash, this mother of two was feeling pretty bad. And then the muscle pain started.
“I met the criteria for a diagnosis of fibromyalgia, but my doctor and physical therapist didn’t really think the official diagnosis was all that critical,” says this previously energetic professional journalist. No matter what anyone called it, conventional medicine offered almost nothing for Shomon.
Instead, she sought out alternative treatments for her fibromyalgia pain. “My doctor’s recommended treatment was to continue the combination of myofascial release bodywork, acupuncture, thyroid hormone replacement, natural sleeping aids, and key dietary and lifestyle changes that I already had in progress,” says this patient turned alternative medicine advocate.
Pain as a Way of Life
What does fibromyalgia really feel like? “Imagine that last night you drank two glasses of wine more than you would have liked, but no water, and eaten no food. You went to bed late, and got up early. You are stiff, achy, and tired—all the time,” says Chanchal Cabrera, member of the National Institute of Medical Herbalists, a prestigious British herbalist, fibromyalgia patient, and author of Fibromyalgia: A Journey Toward Healing (McGraw-Hill, 2002).1
Fibromyalgia syndrome (FMS) is an enigma, and just attempting to digest the swamp of contradictory research and opinions might become a headache of migraine proportions, but this much we know: it involves serious, widespread muscular pain and fatigue. And, if that’s not enough, there’s the loose assemblage of chronic symptoms, including foggy thinking, PMS, and allergies, that’s fairly consistent between patients, but has no obvious laboratory tests.2 Strangely, it overlaps with many other diseases—70 percent of patients also have irritable bowel syndrome, for example.3 When people get sick, with a cold, or after heavy exercise, symptoms often worsen.
Many people feel the worst ache at certain “tender points,” and 18 very common ones actually define the disease. Yet, Cabrera sees no significant correlation with the location or pattern of tender points and takes issue with the whole concept of tender points as a way to diagnose FMS. “It’s ridiculous to base diagnosis on 18 specific points,” she says. “It’s not a fair way to diagnose. It’s just a good clue. A person might have 50 or 100 points and they move around.”
The misery of FMS affects about 2 percent of Americans, making it the second most common musculoskeletal disorder after osteoarthritis.4, 5, 6 Accounting for 10–30 percent of all rheumatology consultations, FMS appears mainly between the ages of 35 and 55 and occurs 7–10 times more frequently in women.7, 8
The Body Blows a Fuse
The cause of FMS remains elusive. But that’s probably because the huge spectrum of symptoms actually starts from many causes. Jacob Teitelbaum, MD, medical director of the Annapolis Center for Effective CFS/Fibromyalgia Therapies, in Annapolis, Maryland, equates FMS to the body “blowing a fuse” if the energy account becomes overdrawn. “The blown fuse is hypothalamus suppression,” Teitelbaum maintains.9 “The hypothalamus controls sleep, hormonal function, temperature, and autonomic functions, such as blood pressure and blood flow. The hypothalamus uses more energy for its size than any other organ. When there is an energy shortfall, it goes offline first. FMS has no one cause,” says Teitelbaum, himself a former FMS patient. The hypothalamus decreases its function as a protection in the face of what it perceives as overwhelming stress, which can stem from infection, injury, or emotions. FMS patients have genetic differences in the stress-handling ability of their hypothalamus, pituitary, and adrenal regulation (the HPA axis). The muscles end up short of energy and in pain.
Can We Turn to Conventional Medical Treatment?
The stigma surrounding fibromyalgia still surprises Shomon. “Those of us who have suffered through it know, from firsthand experience, that it is a very real condition. We didn’t dream it up, wish it upon ourselves, or develop some psychosomatic syndrome, and we can’t just think it away, buck up, and feel better, or ‘get over it’ by sheer determination. Some doctors—and some of our families and friends—even think that fibromyalgia is psychosomatic, evidence of laziness, malingering, or is due to some inherent emotional or character weakness. The fact that fibromyalgia is not visible contributes to the lack of respect you may experience from others,” she says.
Still, many people do better when they find the proper pharmacological regimen. Conventional treatment employs medications to diminish pain and improve sleep, exercise programs that improve muscle and cardiovascular fitness, relaxation techniques to ease muscle tension and anxiety, and lifestyle educational programs to help comprehend the syndrome and manage the symptoms and limitations for life. Medical practitioners may use nonsteroidal anti-inflammatory drugs, such as ibuprofen, analgesics for pain, and tricyclic antidepressants, to improve sleep and blunt pain. Amitriptyline emerges as a good choice for FMS.10 Teitelbaum’s two current favorites are Lyrica (Pregabalin) for pain and Xyrem (GHB) for sleep and pain.11
Noninvasive Treatments that Work
Shomon has fibromyalgia with hypothyroidism. But she feels well now. Starting with bodywork, she surmounted the pain slowly. Turning to herbs to bring restorative sleep, she also took natural hormones to support her endocrine functions. Now, too, she follows a low-glycemic diet with lots of vegetables, fruits, and good protein. “Since that time, I’ve incorporated a Pilates-based exercise program, added more stress-reduction and mind-body efforts, and I no longer have pain,” Shomon declares. These days, she writes popular health books, advocates for patients, and keeps up with an agenda of interviews and appearances.
Massage therapy is excellent for stress management and relaxation. “Fibromites” find bodywork to be the top therapy for providing short-term relief and long-term improvement. This theme gets repeated over and over in patient interviews.12
Massage increases flexibility and oxygenation of the muscles and brings fresh blood and lymph to the sore areas. Many FMS patients gain tremendous relief from massage therapy with the addition of herbal ointments. Clinical investigation found that, surprisingly, menthol-based ointment, applied directly to the tender points, was the most effective out of several types tried.13 Capsaicin (derived from cayenne) ointment, applied to tender points, is also popular.
Muscular pain is the key feature of fibromyalgia, but FMS is probably not primarily a musculoskeletal problem. It is becoming increasingly clear that FMS develops as a result of nervous system imbalances caused by any of the accumulation of genetic and acquired factors. Biomechanical techniques, including massage, ease musculoskeletal discomfort, pain, and restriction, and this area is a critical component of a balanced FMS program that aims to restore balance and health in the short term and long term.
Often combined with ultrasound and/or the application of hot/cold packs, massage may be performed in a number of ways and is useful in soothing and increasing blood circulation to tense, sore muscles. It can also help reeducate muscles and joints that have become mechanically misaligned. Breathing dysfunction is essentially universal in fibromites. Massage, along with breathing training, can help restore proper breathing patterns.
A study of people with fibromyalgia published in The Journal of Clinical Rheumatology found that those who received 30 minutes of massage two times a week for five weeks had less anxiety and depression and lower levels of stress hormones. Over time, they reported less pain and stiffness, less fatigue, and less trouble sleeping. The study concluded what has become a repeated theme: massage therapy is the most effective therapy in these patients.14
Another study compared massage with relaxation therapy for FMS. Twenty-four adult fibromyalgia patients received 30-minute treatments twice a week for five weeks. Both groups showed a reduction in anxiety and depressed mood immediately after the first and last therapy sessions. Only the massage therapy group reported an increase in the number of sleep hours and a decrease in their sleep movements over the duration of the study. Substance P levels decreased, and there were lower disease and pain ratings and fewer tender points in the massage therapy group.15
The European Journal of Pain published a paper on connective tissue massage in FMS. This was a random study of 48 individuals diagnosed with fibromyalgia (23 in the treatment group and 25 in the reference group). The series of 15 connective tissue massage treatments created a pain-relieving effect of 37 percent, reduced depression and the use of analgesics, and positively effected quality of life. The treatment effects emerged gradually over the 10 weeks. Three months after treatment about 30 percent of the pain-relieving effect was gone, and six months after treatment, the pain was back to about 90 percent of the basic value. Again, this illustrates the need for consistency.16
A German study found that massage therapy was one of the four factors found to create the highest degree of satisfaction in patients.17 A nurse practitioner study used a questionnaire to collect information regarding complementary treatments and their effectiveness. Massage was rated among the most effective, along with literature, aromatherapy, support groups, and heat.18
There is evidence that whiplash injury causes damage in the neck that may trigger FMS. This alone speaks to the need to investigate bodywork treatments to treat whiplash before it evolves. Chronic pain resulting from cervical injury in general may be a part of the trigger mechanism of any given case. Many cases of FMS have a history of hypermobility, which has also been implicated as a cause.
Myofascial trigger points are seriously implicated in FMS, at least as far as perceived pain goes. There is evidence that the majority of cases have overlap with trigger point pain, so it seems clear that a good share of the total pain burden for a fibromite is trigger point pain. Manual trigger point therapies probably won’t treat or cure the core myalgia, but they can go a long way toward improving quality of life.
Fibromites virtually always have profound emotional distress. In some people, this may be the original trigger for the syndrome. In others, it might be the result of living with a disabling disease. In any case, massage therapy will promote stress release.
Rub Me the Right Way
Massage for FMS should be done in a warm room, with warming oils. The focus should be on gentle increase of joint range of motion. Since FMS patients have a lack of oily, lubricating “slime” in the tissues, lubricating oil should be used liberally. The patient should not feel any pain during the session.
Cabrera is a big fan of massage for FMS. She says it is an excellent treatment, and may be the best treatment. She says that one of the big benefits is taking an hour to relax from her day. For her personal healing as an FMS patient, the most effective technique was digital pressure applied directly to the tender point. It feels better afterward, and the benefits are cumulative.
Tender points do not have referred pain. Sustained pressure relieves pain. If direct pressure is applied to tender points, it should only “hurt good.”
One of the most critical aspects of massage therapy is the need to continue for what seems like a very long time. According to Cabrera, therapy should continue for years, and hundreds of sessions might be indicated. Patient compliance is critical and difficult to sustain. Though people know they will eventually feel better from their massage appointment, it is difficult for someone in pain to get up and make the effort consistently to go.
Positional release techniques offer a low force or non-force way to adjust muscle and soft-tissue structure and function. Over the years, countless versions have been developed and refined. Many of these approaches have merged, split, and combined numerous times, as is the way of clinical practices. Muscle Energy Technique (MET), a technique frequently practiced by osteopathic physicians, is one of many.
The goal of MET is to relax a muscle spasm and increase range of motion. It is used in cases where there is a need to normalize abnormal neuromuscular relationships, improve local circulation, improve local respiratory function, lengthen or normalize restricted (hypertonic, spastic) muscles and fascia, or mobilize restricted joints. It is a safe and effective way to stretch muscles without inducing further damage. This is a technique that, when applied directly, is based on the principle of reciprocal inhibition, and when applied indirectly, is based on post-contraction relaxation.
MET techniques can be employed in the therapy session when relaxing muscular spasm or contraction, or preparing for stretching, mobilizing restricted joints, and preparing joint for manipulation.
The treatment starts at the barrier for acute problem or for individuals with acute FMS. It will start short of the restriction barrier (mid-range) for a chronic problem.
Rayna Dorsey, LMT, NCTMB, is a licensed massage therapist and experienced bodywork practitioner and educator in Portland, Oregon. In practice since 1984, her private practice focuses on clients with fibromyalgia and chronic pain and trauma survivors. Dorsey describes the MET technique like this:
• Extend the muscle to the first “pathological barrier” (a feeling of being crunchy, pain, discomfort). There may be a “ratchet” or “cog” movement at the barrier.
• Contract, or extend, against resistance, in an isometric contraction.
• Do not push through the barrier.
• The patient holds the breath during contraction.
MET is not limited to FMS and has virtually no research attached to it, but it might be appropriate in a given case to relieve pain and joint dysfunction.
Several other techniques have their proponents. Strain counterstrain, neuromuscular therapy, and passive stretching all have good reputations in the field.
A study on the follow-up to therapy of posttraumatic fibromyalgia patients showed that the vast majority of people with disease of 4–14 years duration had a dramatic reduction in the use of all forms of physical treatments. Even though 85 percent of the patients continued to have significant symptoms and clinical evidence of fibromyalgia, 54 percent continued to use over-the-counter pain medications, and 39 percent were on antidepressants.19
Ya Gotta Move
Each person finds his or her own way on the fibromyalgia path, though this much seems clear: a regular exercise routine stands out as indispensable. With the severe pain, many find it difficult to begin a program and maintain the motivation, but many studies tout the results. In 2006, a paper on exercise in waist-high warm water describes changes in pain and strength that lasted long term.20
According to researchers in New Jersey, yoga and relaxation techniques ease musculoskeletal symptoms. They present a yoga protocol, modified for FMS chronic back pain, in a six-week randomized pilot study.21 The program improves balance and flexibility and diminishes disability and depression, while group processes motivate and foster relaxation and new awareness. Tai chi also makes a good low-intensity exercise choice for sore FMS muscles. In one study, 39 patients took two tai chi classes per week for six weeks and had statistically significant improvement in symptoms and quality of life.22
A New Sugar Sweetens the Treatment
No matter how much they rest, people with FMS just never seem to have enough energy. That’s no mystery, though, because people with FMS have lower levels of ATP, the body’s cellular energy molecule, and a lowered capability to make ATP in their muscles.23 But new research shows that ribose, the body’s cellular fuel, can help them make that ATP again. “Those of you familiar with biochemistry remember ribose as the key building block for making energy,” Teitelbaum says. In fact, the main energy molecules in your body are made of ribose, plus B vitamins and phosphate.”24
D-ribose (or just, ribose), a natural sugar, occurs in all living cells. It appears normally in our diet—brewers yeast has a rich supply—and the body can also make it from glucose in food. Unfortunately, the tissues produce ribose through a slow process and cannot always keep up with energy lost in daily activities, including exercise, so it may take several days to restore the lost ATP.25
Scientists know that supplemental ribose can reduce muscle pain, stiffness, and exercise fatigue, that people tolerate it well, and that it has no side effects.26, 27 A single case report from 2004 describes one FMS patient who improved with ribose. Interest in ribose for FMS gained ground over the last few years.28
Teitelbaum conducted a very promising ribose feasibility study in which patient age and gender matched the FMS population.29 They took five grams of ribose three times a day, for an average of 28 days. In 12 days, 66 percent of those who completed the treatment had significant improvement in energy, sleep, mental clarity, pain intensity, and well-being, with a 44 percent average increase in energy and overall 30 percent bump in well-being. They averaged a 25 percent improvement in quality of life. “It’s for those who want a powerful energy boost,” Teitelbaum says. For some serious added zip, start with 3–5 grams of daily ribose and increase by 3–5 grams additional grams daily until you reach the best level, which might top out at a daily 10–20 grams or more.30, 31, 32
You Don’t Find This Cocktail at a Party
A simple shot might hold the cure for FMS. The Myers Cocktail (named for John Myers, the physician developer), an intravenous micronutrient treatment (IVMT) concoction, containing magnesium, calcium, vitamin B complex, and vitamin C, treats severe pain.
These safe nutrients promote cellular energy production and pump up ATP.33 “We have good clinical success with this treatment to reduce pain and promote detoxification,” says Virginia Hadley, RN, a nutritionist at the eminent Tahoma Clinic, in Kent, Washington.34, 35 Alan Gaby, MD, former Endowed Professor of Nutrition at Bastyr University, in Kenmore, Washington, who popularized the IV treatment, uses it extensively for chronic pain, including FMS, chronic fatigue syndrome, and migraine, all of which involve magnesium deficiency.36 According to David L. Katz, MD, associate clinical professor of Epidemiology & Public Health at Yale University, about 80 percent get good results from IVMT and experience few side effects.37, 38
Needle Me
Many fibromites pin their hopes on acupuncture, and for good reason. Needling increases blood flow more in FMS patients than in healthy people. One study found that 25–35 percent of subjects had a significant decrease in pain. A 2006 study of acupuncture for FMS patients in their 50s reported significant improvement in general symptoms, pain scores, and depression after eight weeks.39, 40
A landmark study appeared in the June 2006 Mayo Clinic Proceedings. This randomized, controlled trial, led by David P. Martin, MD, an anesthesiologist from the Mayo Clinic College of Medicine, in Rochester, Minnesota, reported on 50 FMS patients, 25 of whom received acupuncture, and 25 who got fake needle pokes. After just six treatments over three weeks, the punctured patients reported significant improvement in symptoms, especially symptoms of fatigue and anxiety, which lasted up to seven months after treatment.
Vitamin D Brings New Hope
There’s exciting new information about vitamin D for chronic pain.41 In 2000, scientists published a report that wowed the world. Five wheelchair bound patients, all with severe myopathy, were relieved of their disabling pain after taking vitamin D for four to six weeks.42
We now know this vitamin, which acts as a hormone, is chronically deficient in the population, and such deficiency is suspect in painfully disabled patients.43, 44, 45, 46 On the whole, about 85 percent of Americans measure deficient on standard blood tests. Numerous recent studies have shown vitamin D3 (cholecalciferol) to be anti-inflammatory, immunomodulating, and antimicrobial, and to be surprisingly effective for musculoskeletal pain. We also see a dazzling panoply of newly discovered uses.
The research is so new that no consensus has emerged regarding the right dose, but it’s clear that this Swiss army knife of supplements is not nearly as toxic as was heretofore thought. Experts agree that daily doses of 1,000 IU per day are safe, and some suggest even higher maintenance doses.
Finding Help
“One of the hardest parts of fibromyalgia is perhaps the fact that you need to tackle this huge challenge—figuring out which practitioners to see and the best treatment approaches—at a time when you’re most likely in pain, feeling exhausted, and often brain-fogged,” Shomon says. Talk about a wrong time to try to delve into a complicated medical topic!” It requires diligence, and some help, to conquer this complex disorder, but conquer it you can. With treatment, most people will feel better over time.
“With a condition like fibromyalgia, I urge patients to trust their own instincts,” says Shomon, wearing her advocate hat. “You may choose to find a practitioner who inspires your utmost trust, confidence, faith, and hope, and follow his or her direction,” she says.
“I did not come upon one single protocol, treatment, or approach that is a ‘cure’ for fibromyalgia,” Shomon says. “People with fibromyalgia do best when treated with a person-centered approach that includes treatments from among many options—supplements, nutrition, diet, mind-body, medication—to address the person’s unique needs.”
These days Shomon is feeling much better. “My fibromyalgia trigger points flare very rarely now,” she says. “I manage to keep up a somewhat busy schedule on eight to nine hours of sleep a night. I no longer have pain.”
Karta Purkh Singh Khalsa is the author of Fibromyalgia: a Text for Massage Therapists (Natural Wellness, 2004). The book is available from the author. Contact him at integrative_education@msn.com.
Notes
1. Personal communication.
2. Robert H. Friedman, “Fibromyalgia 101: The Basics,” Arthritis Foundation. Available at www.arthritis.org/communities/chapter/uti/archives/fm_connect/basics.asp (accessed April 2009).
3. Anne Barton et al., “Increased Prevalence of Sicca Complex and Fibromyalgia in Patients with Irritable Bowel Syndrome,” American Journal of Gastroenterology 94, no. 7 (July 1999): 1898–901.
4. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Available at www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm (accessed April 2009).
5. Fibromyalgia Fact Sheet, American College of Rheumatology. Available at www.rheumatology.org/public/factsheets/fibromya.asp (accessed April 2009).
6. “What is Fibromyalgia?” Arthritis Foundation. Available at www.arthritis.org/AFStore/StartRead.asp?idProduct=3322 (accessed April 2009).
7. Marcia Zimmerman, “Persistent Pain,” Nutrition Science News (October 1999). Available at www.newhope.com/nutritionsciencenews/NSN_backs/Oct_99/fibromyalgia.cfm?path=ex (accessed April 2009).
8. RM Bennett, “Beyond Fibromyalgia: Ideas on Etiology and Treatment,” Journal of Rheumatology Supplement 19 (November 1989): 185–91.
9. Personal communication with Teitelbaum.
10. S. Carette et al., “Evaluation of Amitriptyline in Primary Fibrositis. A Double-Blind, Placebo-Controlled Study,” Arthritis & Rheumatism 29, no. 5 (May 1986): 655–9.
11. Q & A with Jacob Teitelbaum, MD: Treating the Pain and Fatigue of FM and CFS Comprehensively, 11-16-2005. Available at www.chronicfatiguesyndromesupport.com (accessed April 2009).
12. Karta Purkh Singh Khalsa, Fibromyalgia, a Text for Massage Therapists (Pine Bush, New York: Natural Wellness Publishing, 2004).
13. Ibid.
14. W. Sunshine et al., “Massage Therapy and Transcutaneous Electrical Stimulation Effects on Fibromyalgia,” Journal of Clinical Rheumatology 2 (1996): 18–22.
15. Tiffany Field et al., “Fibromyalgia Pain and Substance P Decreases and Sleep Improves Following Massage Therapy,” Journal of Clinical Rheumatology (2002).
16. G. Brattberg, “Connective Tissue Massage in the Treatment of Fibromyalgia,” European Journal of Pain 3, no. 3 (June 1999): 235–44.
17. J. Wild and W. Muller, “Patient Satisfaction in the Rehabilitation of Fibromyalgia Inpatients,” ZRheumatology 61, no. 5 (October 2002): 560–7.
18. Connie Barbour, “Use of Complementary and Alternative Treatments by Individuals with Fibromyalgia Syndrome,” Journal of the American Academy of Nurse Practitioners 12, no. 8 (August 2000): 311–6.
19. G.W. Waylonis and R.H. Perkins, “Post-traumatic Fibromyalgia. A Long-term Follow-up,” American Journal of Physical Medicine & Rehabilitation 73 (1994): 403–12.
20. N. Gusi et al., “Exercise in Waist-high Warm Water Decreases Pain and Improves Health-Related Quality of Life and Strength in the Lower Extremities in Women with Fibromyalgia,” Arthritis & Rheumatism 55, no. 1 (February 2006): 66–73.
21. Mary Lou Galantino et al., “The Impact of Modified Hatha Yoga on Chronic Low Back Pain: a Pilot Study,” Alternative Therapies in Health and Medicine 10, no. 2 (March–April 2004): 56–9.
22. F. Li et al., “Tai Chi and Self-rated Quality of Sleep and Daytime Sleepiness in Older Adults: a Randomized Controlled Trial,” Journal of the American Geriatrics Society 52, no. 6 (June 2004): 892–900.
23. “CORvalenTM (D-Ribose) Improves Pain And Quality Of Life In Fibromyalgia And Chronic Fatigue Patients,” Medical News Today, February 9, 2006. Available at www.medicalnewstoday.com/medicalnews.php?newsid=37399 (accessed April 2009).
24. Personal communication with Teitelbaum.
25. D-Ribose, PDRHealth. Available at www.pdrhealth.com/drug_info/nmdrugprofiles/nutsupdrugs/dri_0226.shtml (accessed April 2009).
26. D.R. Wagner et al., “Effects of Oral Ribose on Muscle Metabolism During Bicycle Ergometer in AMPD-deficient Patients,” Annals of Nutrition and Metabolism 35, no. 5 (1991): 297–302.
27. N. Zollner et al., “Myoadenylate Deaminase Deficiency: Successful Symptomatic Therapy by High Dose Oral Administration of Ribose,” Wien Klin Wochenschr 64, no. 24 (December 1986): 1281–90.
28. Benjamin Gebhart and James A. Jorgenson, “Benefit of Ribose in a Patient with Fibromyalgia,” Pharmacotherapy 24, no. 11 (November 2004): 1646–8.
29. Jacob E. Teitelbaum and Clarence Johnson, “Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia with D-ribose.”
30. Jacob E. Teitelbaum et al., “Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia—a Randomized, Double-Blind, Placebo-Controlled, Intent to Treat Study,” Journal of Chronic Fatigue Syndrome 8, no. 2 (2001): 3–28.
31. Jacob E. Teitelbaum, “Effective Treatment For Chronic Fatigue, Fibromyalgia and Muscle Pain.” Available at www.vitality101.com (accessed April 2009).
32. H. Blatman, “Effective Treatment of Fibromyalgia and Myofascial Pain Syndrome: A Clinician’s Perspective,” Journal of the American Academy of Pain Management, 12, no. 2 (April 2002): 67–8.
33. Derrick Lonsdale et al., “Evaluation of the Biochemical Effects of Administration of Intravenous Nutrients Using Erythrocyte ATP/ADP Ratios,” Alternative Medicine Review 4, no. 1 (February 1999): 37–44.
34. Personal communication.
35. J. Wright, “Cocktail Hour,” Nutrition and Healing Newsletter. Available at www.wrightnewsletter.com/etips/ht200504/ht20050418.html (accessed April 2009).
36. Alan R. Gaby, “Intravenous Nutrient Therapy: the “Myers’ Cocktail,” Alternative Medicine Review 7, no. 5 (October 2002): 389–403.
37. Jennifer Arnold, “Heal Thyself—Spotlight on Fibromyalgia.” Available at www.alternativemedicine.com/common/news/store_news.asp?task=store_news&SID_store_news=415&storeID=02AD61F001A74B5887D3BD11F6C28169 (accessed April 2009).
38. A.B Sabina et al., “Nutritional Treatments for Fibromyalgia,” National Fibromyalgia Association 5, no. 4. Available at http://fmaware.org/fmOnlineNewsletter/2005/vol5_no4/article_nutritional.htm (accessed April 2009).
39. R.E. Harris et al., “Treatment of Fibromyalgia with Formula Acupuncture: Investigation of Needle Placement, Needle Stimulation, and Treatment Frequency,” Journal of Alternative and Complement Medicine 11, no. 4 (August 2005): 663–71.
40. B.B. Singh et al., “Effectiveness of Acupuncture in the Treatment of Fibromyalgia,” Alternative Therapies in Health and Medicine 12, no. 2 (March-April 2006): 34–41.
41. S. Faiz et al., “The Epidemic of Vitamin D Deficiency,” Journal of the Louisiana State Medical Society 159, no. 1 (January–February 2007): 17–20, quiz 20, 55.
42. Anu Prabhala et al., “Severe Myopathy Associated with Vitamin D Deficiency in Western New York,” Archives of Internal Medicine 160, no. 8 (April 2000): 1199–203.
43. Leonid M. Shinchuk and Michael F. Holick, “Vitamin D and Rehabilitation: Improving Functional Outcomes,” Nutrition in Clinical Practice 22, no. 3 (June 2007): 297–304.
44. D.J. Armstrong et al., “Vitamin D Deficiency is Associated with Anxiety and Depression in Fibromyalgia,” Clinical Rheumatology 26, no. 4 (April 2007): 551–4.
45. Robert D. Gerwin, “A Review of Myofascial Pain and Fibromyalgia—Factors that Promote Their Persistence,” Acupuncture in Medicine 23, no. 3 (September 2005): 121–34.
46. A.M. Huisman et al., “Vitamin D Levels in Women with Systemic Lupus Erythematosus and Fibromyalgia,” Journal of Rheumatology 28, no. 11 (November 2001): 2,535–9.