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    Fibromyalgia and Fatigue
    Mark Pellegrino, MD posted:
    Our dear MiMI recently asked about fatigue and I wanted to discuss it a bit.

    Fibromyalgia's top two symptoms are widespread pain and fatigue. If fatigue were cement, we would be freshly paved with particular heavy concentrations on our eyelids, arms, and feet!

    There are multiple factors involved in our fatigue and they include:
    1. Non-restorative sleep disorder. As we've previously discussed, restoration that should be occurring during the deep stage 4 of sleep is not happening. Poor sleep leads to increased fatigue.
    2. Deconditioned muscles. Our fibro muscles are chronically low in energy molecules called ATP and our muscles do not use oxygen as well as normal muscles.
    3. Constant pain. The body's process of monitoring pain, recording pain, and expressing pain is energy consuming so we use up a lot more energy.
    4. Cognitive factors. Fatigue is influenced by our difficulty with concentration, attention, absentmindedness, i.e. our fibro fog.
    5. Associated conditions contributing to fatigue. This could include depression, a co-morbidity of fibro, and non-fibromyalgia problems such as arthritis, hypothyroidism, etc. that consume a lot of energy and contribute to excessive fatigue.
    6. Dysfunctional autonomic nervous system. This leads to dysfunctional breathing, increased heart rate and more stress responses, all of which consume energy or create oxygen delivery inefficiencies.
    7. Hormone problems. People with fibro have lower growth hormone levels, usually have lower thyroid levels, and have insulin hypersensitivity and other hormone dysfunctions which decrease energy, metabolism and increase fatigue.
    8. Deficiencies. This can include low vitamin D, low magnesium, low B12 and other key ingredients that are used to manufacture ATP or improve our metabolism.
    9. Constant muscle movements. We are shifty people! I mean we frequently shift our bodies to find more comfortable positions. We also have habitual movements such as tapping our fingers, bouncing our feet or crossing/uncrossing our legs. The side effect of these movement patterns is increased energy consumption.

    I find that fatigue is a difficult problem to treat. But there are many strategies for treating fatigue. Like your fibro pain, fibro fatigue will probably never be completely eliminated but you try to minimize its impact on everyday life. Your doctor will work with you to investigate for underlying diseases or other causes of fatigue.

    What steps can be done? Here's a list of strategies I have found helpful:
    1. Develop good sleep habits.
    2. Avoid long daytime naps. Naps in general are non-refreshing, time consuming, and sleep rhythm disrupting.
    3. Proper nutrition. We previously discussed dietary strategies.
    4. Supplements. Examples of supplements that have been used include magnesium, vitamin D3, vitamin B12, coQ10, growth hormone, and 5-HTP. I believe supplements should be used only after discussion and recommendation by your treating doctor.
    5. Prescribed medicines. These medicines are known as alerting agents and can include SSRIs, central nervous system stimulants, and other medicines under the direction of your treating physician.
    6. Perform regular exercise and don't forget about regular relaxation.
    7. Make a daily schedule and check off things as you accomplish them. Plan scheduled activities, divide your planned task into smaller projects instead of one big one.
    8. Don't forget to follow proper fibronomics!
    9. Delegate chores to others. This is one of the best energy saving techniques known where someone else uses his/her energy to do your task!

    Hopefully some of these weapons can help you combat fatigue. And hopefully I didn't wear you out with this discussion!

    Dr. P

    meesh69 responded:
    Dr. P,

    Does the dysfunctional autonomic nervous system have anything to do with my body's inability to handle stress? I keep meaning to ask my doctor about this. When stressful situations happen it feels like my mind can handle it, but my body freaks out. I do not feel the stress mentally, but I start shaking, having heart palpitations and sweating. I would greatly appreciate any input on this.

    Also thank you for this post, it was very informative. I also really appreciate your post on profuse sweating. It does not seem like other doctors know about this. I was very frustrated when I mentioned the sweating to my Rheumatologist and he said, "pre-menopause?" I am 40 and have no other symptoms of this, plus he said it in a humorous condescending way.

    Thanks again!
    bcbailey1977 responded:
    I think I have the fatigue from both fibro and chronic fatigue syndrome. I take dexedrine spanules 3x a day to keep me functional at work, on task for 10 minute bits.

    My fatigue comes from work. I am trying to show people how to do stuff for when I am off at the end of my mom and another week to help my dad amongst other things

    Stress now with my mom's latest diagnosis-3 months or so to live, cancer.

    I have energy in the morning but at night after work, I am useless but every once in a while I will get a burst of energy and I will start something and can't finish it because I get tired. I try to do stuff in 5 minute increments with a timer. Then increase by 1-2 minutes each day. I am at 10 minutes and I am not going to try to go any higher.
    An_199392 responded:
    Hi, Dr. Pellegrino!

    Another grand discussion, and one that is much needed.

    I recently stopped "all" supplements due to an extreme flare with my stomach. I have realized that they were helping a lot with my muscle weakness and pain.

    I cannot even fold a load of laundry without stopping to rest my arms!! I would think that this is increasing my fatigue level.

    I would like to eventually try taking Magnesium, CoQ10, and Colostrum again! Do you think that these supplements are "stomach irritants"? I am fearful of a repeat stomach flare.

    I am, also, interested in "growth hormone". How is this sold? Is the supplement labeled Growth Hormone or something else? Again, do you feel that this would be ok for my stomach?

    I have been debating the use of "Provigil" for a long time now. Is it a safe med? I am really getting to the point where I feel that the benefits will outway any side effects.

    I would love to delegate chores but I have a 17 year old who won't even take out the garbage! My 29 year old daughter who used to help a lot has stopped for some reason.

    I am now struggling to just keep up with daily chores. This is probably, also, increasing my fatigue level.

    I wish that "all" doctors were as educated about Fibro as you are! You have definitly helped me to "live" life.

    Thank you!
    annette030 responded:
    Hi, Dr. P

    What drugs would you include as central nervous system stimulants for use in FMS? Have any of these been actually tested in FMS or is the information more anecdotal?

    Being a child of the sixties, I remember when speed and valium were both heavily prescribed to sharpen us up and put us to sleep. They scare me, frankly. I won't take any benzos, because I had a bad reaction to them twice in the past. I doubt I would ever take any kind of stimulant either due to fear only.

    I am interested in your opinion.

    Take care, Annette
    Dollbug responded:
    Hello Dr. P.....MiMi in NC....I had a long, very long stress again....which I could only hope would get settled....but I think this is going to be a lifetime it does involve my older son and my sweet little granddaughter....who is only 6 years with this being said....there is not a whole lot that I can do to "control the situation".....

    And yes....I do think that this is part of my health issues....

    I do try to follow most everything that you suggested....I have to still sleep in the recliner.....and have done so for so long...I still try every now and lie down on the mattress....

    I seem to have problems in this position....I get all stopped I guess the recliner is what I have to do for now... day I will be able to get one of the adjustable beds...(I can hope)

    I have learned how to pace, pace and pace...and I can now tell when I am getting to the point of "crossing my line"....and I know then that it is time to rest....whether I like it or not...

    I do get in "trouble" sometimes....and I know that with the holidays approaching....this is going to happen even more....because there are times...when a person can not just stop....(this happened to me last I was cooking)....I was in trouble and knew it....but I was in the middle of cooking...(not a good place to be)...

    I know that I can get so much more done....(in my mind) than I can physically do...and I hate I was one of those people who was more like the energizer bunny....who could keep going and going....and still go some more....and I now know that this is not going to happen...

    I do try to plan things...but sometimes, I still get in trouble with myself....(not a good feeling either)

    Anyway....thanks again for sharing your wonderful knowledge with us....and your humor fit right in here with our FMily....

    Take care.....

    IN GOD WE TRUST....MAY GOD BLESS AND GUIDE AMERICA.... My personal exchanges are Vitamin D and Pain and Wrath of the Dragon....if you care to visit..
    Mark Pellegrino, MD replied to annette030's response:
    Hi Annette,

    Central nervous system stimulants that have been used off-label for FM-related fatigue/cognitive symptoms include modafinil (Provigil), pemoline (Cylert), methylphenidate (Ritalin), dextroamphetamine (Adderall). Theses meds are primarily indicated for narcolepsy or ADD, but there are medical studies/medical evidence and anecdotal information that support their use in certain patients with FM-related fatigue and cognitive dysfunction.

    Dr. P
    An_199393 replied to Mark Pellegrino, MD's response:
    I am guessing that you don't have any addition input for my questions that I posted. Thanks anyway.
    purpleopal1957 responded:
    Thank-You!!! i found this article very help ful!!! i wish my printer worked so i could print it out.i have suffer oner 25 years with fibro amd chronic fatigue and as a teen i had mono so i find youre discussion very interesting!!!!
    Caprice_WebMD_Staff replied to purpleopal1957's response:
    Hi Purpleopal and welcome to WebMD!

    You may want to copy and paste it to a document on your computer to keep and refer to and/or click to watch this discussion so you can always find it when you're on WebMD and look at your discussions via the left sidebar when signed in here. :-)
    We must let go of the life we have planned, so as to accept the one that is waiting for us. ~Joseph Campbell
    Asagrace replied to bcbailey1977's response:
    I can so identify with this! If I get a burst of energy and start a project, usually it's to pull out a big mess to go through it, throw away, and organize what's left, or filing a pile of unfiled papers. Then I run out of energy, and I've got an even bigger mess than I had to start with as it might be weeks before I feel like getting back to the "project" and by then, I have no idea where I am or where to start. Life is a constant struggle, and a cycle of fresh will, worn out will, despair, depression, and then back on the up side of the cycle again. Some days it does not seem worth it to even try. Other days trying seems reasonable and life is fairly good. It's an emotional roller coaster as well as physical. I can only believe that God has a purpose for allowing this and some good will come of it. I know I need to encourage other people whenever I can and that makes my life significant. Reading God's word (especially the Psalms) is essential for me and encouraging; it helps me cope, it increases my faith, and my insight. God bless you dear one.
    Asagrace replied to An_199392's response:
    You need to get tough with the children but when you are in the throes of fibromyalgia and barely getting through a day, getting tough with kids is extremely hard. Been there on that one. I wish I had tried harder, but the fighting and arguing were too much, What I should have done was lay down the law and say you will do this or that to help out or you will live somewhere else - no fight, no argument, just facts. I think it would have helped them as well as me. I'm interested in the growth hormone too - help somebody! I do the coq10 and magnesium, plus other supplements. They don't seem to help but I'm afraid if I stop them, I'll be even worse. Provigil did not work for me, it made me sneeze 12 hours a day, besides being outrageously expensive. I have heart disease and high blood pressure, so I can't take dexedrine or that type med. I pray you will get relief soon!
    lolly2creates replied to Asagrace's response:
    I fibro fog: Before fibro I was 100% energizer bunny at the age of 63! Now like you my whole personality and energy has changed. I didn't like the fact that I couldn't shop for 3 hrs, put it away, and then house or yard work. it was very depressing until I learned to acept it. I, like you, am not as organized as I once was. " Miss organizer has left the building" never to return! Everything had its place and if there was dust I freeked. No more. We just do what we can, work at it, rest, come back when you are ready.
    I try VERY hard not to complain. My role models are a friend you has MS and never, ever complains; and my dearest and much loved Uncle who has ALS. It works for me.
    Asagrace replied to Dollbug's response:
    A BIG problem for me - planning things in my mind that my body refuses to carry out! I have also wasted a lot of money like buying seeds and plants that never get planted, supplies for projects that never get done. It is so HARD to realize that I cannot do anything beyond what is absolutely necessary to life on a daily basis. Anybody got any suggestions on being realistic about this? It seems like I'm into some plan before I realize it because my mind and body do not match. God bless us and help us adjust to our reality. We have to deal with what is, not what we want it to be.
    bcbailey1977 replied to Asagrace's response:
    I am so tired of not being able to walk around my room from my "started but not finished projects" that I am gonna just throw everything in my heavier shopping bags from the stores and then do my project for the weekend which is move my room around a bit because it doesn't work for me in the way I need it to. I just need to purge everything.

    Wish me luck

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