September 2000
Seasonal Affective Disorder
Every autumn I undergo a transition. At
first the change is subtle: I become less energetic,
I start taking more naps and sleep longer
(although I do not sleep "well"), my craving
for junk foods increases and in general the
glass appears "half empty" rather than "half full".
I have been aware for many years that I "changed"
in the winter. However, it wasn't until 10 years
ago that I realized I suffered from Seasonal
Affective Disorder (SAD).
I was very fortunate in that what I accepted
as "Winter Blues" or "Cabin Fever" (something
that didn't make sense since I was always very
active in the outdoors during winter- skiing,
snowshoeing etc.) was discovered to be a treatable
clinical entity.
Right now I am sitting in front of my computer
with a very bright therapeutic light about 18" from
my face. I have reduced the glare on the monitor
with an anti-glare/anti-radiation screen, although
to be honest the "UltraLight" light box is so bright
that there is still some reflection on the monitor,
but I can still work. Over the years I have learned
that I should start my Light Therapy sessions around
Labor Day. However, I often start later because I
need the motivation of realizing I am getting "weird"
before I acknowledge that I need to have Light Therapy.
You would think that after 10 years of successful
therapy, I would not experience the same denial every
September.
The "UltraLight" Therapy Light delivers
10,000 Lux of light at 18". This is the recommended
"dosage" and it works well for me. I begin with
15 minutes/day exposure and build up to as much as
an hour as the days grow even shorter.
SAD is a recognized clinical entity generally
occurring from autumn until spring. It is estimated
that 6% of the U.S. population may suffer with SAD,
with an additional 14% experiencing lessor
manifestations with some but not most of the symptoms
(subsyndromal SAD). The incidents is directly related
to the latitude you live at, with nearly 10 times
the number of people experiencing the syndrome in
New Hampshire than in Florida.
The most prominent symptoms are:
- change in appetite (especially a craving
for sweet or starchy foods)
- weight gain
- drop in energy level
- reduction in sex drive
- change in sleep/wake patterns (especially
a tendency to oversleep)
- reduction in quality of sleep
- avoidance of social situations
- decreased concentration
- decreased creativity
- irritability
- inability to complete tasks.
If you have experienced many or all of the
above described symptoms, and they seem seasonal
or even occur after prolonged light deprivation
(i.e. extended cloudy periods or a dark work
environment) you may suffer with SAD.
I began using my UltraLight last week. I
noticed improvement within a few days. I was unable
to sit down and write this article until I used the
light for a few days, so I guess once again it is
helping. I do not look forward to the extended
darkness of winter, but I do not dread it like I
did when I was younger. Phototherapy has
significantly improved my life. Because of it I was
able to complete this article!
I will present a more detailed article on the
science of SAD in the future. If you desire more
information sooner check out "Winter Blues-
Seasonal Affective Disorder: What it is And How
To Overcome It" by Norman E. Rosenthal (The Guilford
Press New York 1993). There are also many articles
available in the scientific community, many of which
are available on the World Wide Web.
DMS
Lifewithease.com has three choices of Phototherapy lights.
Our standard unit is The BriteLight at:
http://www.lifewithease.com/britelite.html
Our conveniently small portable unit is
The Sun Light Junior at:
http://www.lifewithease.com/sunjr.html
Our unit for people who need to be on the move is
The Deluxe Visor at:
http://www.lifewithease.com/visor.html
June 2000
FibroMyalgia Syndrome (FMS): Part I
For those of you that don't know it, I have practiced as a Doctor of Chiropractic for 20 years. I still care for a few friends, neighbors and relatives, which I suppose means I still practice. Chiropractic is a very rewarding profession since many patients come to you after being treated as an "incurable" by many other health professionals, only to find that what they needed all along was proper Chiropractic care. They then became very appreciative people (I received many hugs, kisses and pats on the back). I mention all this because this health care experience has exposed me to many patients with Fibromyalgia Syndrome (FMS), and that is the topic for this and the next newsletter.
Although I was able to help many patients with FMS, I never saw a patient with FMS have their problems resolved. Until 1990 when the American College of Rheumatology (ACR) set diagnostic criteria for FMS, health care providers often did not diagnose and treat the condition properly and many still do not. There are no laboratory or X-Ray tests to help diagnose FMS. Testing is done to rule out other causes of the symptoms. However, knowing there are other conditions occurring does not rule out the existence of FMS occurring in conjunction with other conditions (in fact, a number of diseases demonstrable with lab and X-Ray tests are known to occur along with FMS ). Diagnosis of FMS is based on a properly taken patient history, along with certain definitive physical findings. FMS is a syndrome. An entity defined by a group of related symptoms. This designation in no way diminishes the seriousness of the condition, it just denotes our failure of finding definitive diagnostic lab or X-Ray tests.
The American College of Rheumatology (ACR) set the following criteria:
- 1) widespread pain for more than 3 months 2) pain involving any or all areas of the spine
- 3) fatigue, depressed mood or clinical depression, (although only about 20% have a true clinical depression or anxiety state accompanying FMS) 4) muscle stiffness
- 5) irritable bowel symptoms
- 6) headaches
- 7) tenderness at more than half of the fibromyalgia tender-point sites. The pain of fibromyalgia is generally widespread, involving both sides of the body as well as above and below the waist and the front and back. Pain usually affects the neck, buttocks, shoulders, arms, the upper back, and the chest. "Tender points" are localized tender areas of the body that can bring on widespread pain and muscle spasm when touched. Tender points are commonly found around the elbows, shoulders, knees, hips, back of the head, and the sides of the breast bone. There are 18 designated tender points that should be checked .
Fatigue occurs in 90 percent of patients. Fatigue may be related to abnormal sleep patterns commonly observed in these patients. Normally, there are several levels of depth of sleep. Getting enough of the deeper levels of sleep may be more important in refreshing a person than the total number of hours of sleep. Patients with FMS lack the deep, restorative level sleep, called "non-rapid-eye- movement" (non-REM) sleep. Consequently, patients with FMS often awaken in the morning without feeling fully rested. Some patients awaken with muscle aches or a sensation of muscle fatigue as if they had been "working out" all night!
Fibromyalgia Syndrome is certainly not a new problem. Reference to the syndrome can be found in the early nineteenth century. It appears to afflict women far more than men. Estimates run as high as 20:1 with a general consensus of 8:1. Although, this seeming preponderance of females may be somewhat due to failure to identify the problem in as many men (men do not seek medical help as often as women). The most common age group for FMS to be identified is in 35 to 55 year olds, although the range of 20 to 55 year olds is sometimes given.
Unfortunately, FMS has not been taken seriously until fairly recently, and much to the dismay of the sufferers it is still misdiagnosed and thought of as being a problem "in their heads" or a form of masked depression or hypochondriasis.The ACR diagnostic criteria have made it much easier for the problem to be diagnosed.
Although the term fibrositis is often used analogously with FMS it is misleading since there is no true inflammatory process occurring. That is why the common non steroidal anti-inflammatory medications (aspirin, ibuprofen,etc.) are not much help with FMS. FMS has often been confused with Chronic Myofascial Pain Syndrome(CMPS). However, with this syndrome there are discrete pain trigger points which will cause pain to spread when stimulated with pressure (with FMS the pain is localized), and there is the absence of the other criteria set forth by the ACR.CMPS is far more successfully treated. What can be really confusing is that CMPS can coexist (and often does) with FMS.
So we now know that FMS is a diagnosable entity with
discrete physical manifestations which can be confused with and occur concurrently with other known diseases and pain syndromes. We also know that it is currently incurable. However many have benefited from numerous treatments, and that will be the topic of my next newsletter.
Donald M. Swartz D.C.
July/August 2000
FibroMyalgia Syndrome (FMS): Part II
In June, I presented the diagnostic criteria for FibroMyalgia Syndrome (FMS), as well as discussed it's numerous manifestations (if you wish to review that newletter it is posted below this article. The question I hope to answer now is how can a person living with FMS best survive this burden..
To best approach this answer we must have some understanding of what the cause of this syndrome may be. Many scientific professionals, myself included, adhere to a yet unproven theory that FMS is most likely due to a metabolic disorder. The theory is that there is an error in one (or more) of the chemical pathways which break down the by-products of muscle metabolism..
We can think of muscles as small engines which burn sugars as fuel, utilizing oxygen in the process, and yielding carbon dioxide, water and metabolic waste products (such as lactic and hyaluronic acid, among others). In a healthy individual these metabolic by-products are broken down fast enough to be rapidly eliminated by the body via the kidneys and liver (i.e. urine and feces). In FMS patients there is a build up of these metabolic by-products in the muscles (they breakdown to simpler substances but more slowly). The body responds by tightening the muscles in certain areas which restricts circulation. These tightened areas are the "Trigger" areas referred to in the last newsletter. Using this model for understanding we can formulate an approach for treating FMS.
Since the body's metabolism is not processing these irritants quickly enough, we need to speed the process up. The first thing that must be tried is an aerobic exercise program. Walking, swimming, biking or stationary cross-country ski machines are probably the best. This must be started gradually with a steady increase in effort. This will increase the rate of metabolism in the muscles thus helping the elimination of the built up irritants, as well as improving your overall cardiovascular fitness. I mention aerobic exercise first because it is the essential back drop to the rest of the approach to FMS treatment.
The direct treatment of the "trigger" areas is going to also aid in the elimination of the metabolic by-products. Myofascial release techniques, in conjunction with regular stretching, should be applied and instructed by a health care professional. There are numerous approaches that may be used. Since the more aggressive deep pressure techniques are not well tolerated by some, you might opt for electrical stimulation of the trigger areas or more gentle massage techniques. But whatever you choose, you must do it on a regular basis as directed by your chosen health professional.
You will want to increase the circulation in these areas to aid in the body's elimination of the metabolic by products. This is best done with the application of heat (preferably moist). This can be accomplished with a moist heating pad, a hot tub soak, or (if your lucky enough to have one) a jaccuzi. The use of Inversion therapy will also improve circulation. Since restricted joint motion will contribute to muscle tightness as well as many other deleterious effects, you should have a highly skilled manual therapist as part of your health team. By the way, Inversion therapy also helps to maintain proper joint motion by decompressing the spine.
Now those of you who have FMS are probably wondering how you will find the energy to do all these things. A major part of the overwhelming fatigue experienced by those with FMS is due to poor sleep. They awaken in the morning without feeling fully rested. Achieving deep restorative sleep will be helped by the aerobic exercise. However, you can also be helped with the use of Serotonin Re-uptake Inhibitors (SRI's) like Zoloft or Paxil. Your medical physician will be familiar with the use of these medications. You will be amazed at how much better you can feel with improved sleep.
Other symptoms of FMS should be treated symptomatically. Irritable Bowel can be treated with dietary changes and medications. The accompanying depression that some experience may be helped with the SRI's taken for improving sleep. It is also very important to get involved with a FMS support group. You will realize you are not alone and you will find sources for the most recent theories on causes and treatments. You should be able to locate a support group through a hospital pain control center or do a search on line. You can check the following link at the National Fibromyalgia Research Association web site, http://www.nfra.net/ for good leads. Although it should probably be a last resort, analgesic (pain) medication can help, but be aware that anti-inflammatory medications will probably be no better than acetominophen (tylenol) and may cause digestive tract bleeding.
I hope you found my discussions on FibroMyalgia Syndrome interesting and if you suffer with this syndrome I hope I have been of help. I have tried to pass on my knowledge from my studies and experience and welcome your input. If you know of good resources on FMS please send them to me. Let me know what you think, and help me to know more that I can share.
Donald M. Swartz D.C.
MAY 2000
Depression
Depression Information from the NIMH
Over 19 million American adults suffer from depressive
illnesses. Depressive illnesses are serious but treatable
disorders. Depressive illnesses are more than temporary
"blue" moods or periods of grief after a loss. Symptoms
of depression affect thoughts, feelings, body,and behaviors.
Without treatment, the symptoms can last for months, years,
or a lifetime. Depressive Illnesses come in various forms.
Some depressive episodes occur suddenly for no apparent
reason. Some are triggered by a stressful experience.
Some people have one episode in a lifetime; others,
recurrent episodes. Some people's symptoms are so severe
they are unable to function as usual. Others have ongoing,
chronic symptoms that do not interfere with functioning,
but keep them from feeling really well. Some people have
bipolar disorder (also called manic-depressive illness).
They experience cycles of terrible "lows" and inappropriate
"highs."
Depressive illnesses take a staggering toll:
They cause great pain to millions of people. The lives of
families and friends are affected, often seriously disrupted.
They hurt the economy, costing an estimated $30.4 billion
in 1990.
Many Do Not Recognize Their Illness:
Nearly two-thirds of depressed people do not get appropriate
treatment because their symptoms: Are not recognized; Are
blamed on personal weakness; Are so disabling that people
cannot reach out for help; Are misdiagnosed and wrongly treated.
Symptoms of Depression:
Persistent sad or "empty" mood; Loss of interest or pleasure
in ordinary activities, including sex; Decreased energy,
fatigue, being "slowed down"; Sleep disturbances (insomnia,
early-morning waking, or oversleeping); Eating disturbances
(loss of appetite and weight, or weight gain); Difficulty
concentrating, remembering, making decisions; Feelings of
guilt, worthlessness, helplessness; Thoughts of death or
suicide; suicide attempts; Irritability; Excessive crying;
Chronic aches and pains that don't respond to treatment.
Depression with Other Illnesses:
Depression often co-occurs with medical, psychiatric, and
substance abuse disorders, though it is frequently unrecognized and untreated. This can lead to unnecessary suffering since depression is usually treatable, even when it co-occurs with other disorders. Individuals or family members with concerns about the co-occurence of depression with another illness should discuss these issues with the physician. With available treatment, 80 percent of the people with serious depression,even those with the most severe forms- can improve significantly. Symptoms can be relieved, usually in a matter of weeks. There are effective medications and psychotherapies (talk therapies), treatments that often are used in combination. In severe depression, medication is usually required. A number of short-term talk therapies to treat clinical depression have been developed in recent years. Several types of medications are available, none of them habit-forming. People with severe depression respond more rapidly and more consistently to medication. Those with recurring depression, including bipolar disorder, may need to stay on medication to prevent or lessen further episodes. Many patients need psychotherapy to deal with the psychological or interpersonal problems often associated with their illness. Other biological treatments can be helpful. For example, electro-convulsive treatment (ECT) is a safe and often effective treatment for the most severe depressions. Research also supports the use of light for the treatment of some depression. Early intervention may lessen severity of symptoms and shorten the episode. Individuals respond differently to treatment. If after several weeks symptoms have not improved, the treatment plan should be re-evaluated. Individuals respond differently to treatments.
If after several weeks symptoms have not improved, the
treatment plan should be discussed with the doctor.
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