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PAPERS: Selwyn C M Richards and David L Scott Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial BMJ 2002; 325: 185 [Abstract] [Full text]

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Rapid Responses published:

The Findings of Selwyn, et al., May Be Due to Increased DHEA

James M. Howard   (27 July 2002)

Our experience with fibromyalgia

Shiju Majeed   (28 July 2002)

Fibromyalgia put on the front page

Martin Westby   (30 July 2002)

Missing data and compliance with oversimplification

A Chaudhuri   (1 August 2002)

Further Discomforts of Patient Power.

Horace Reid   (7 August 2002)

Fibromyalgia needs pragmatism

Joe McVeigh   (9 August 2002)

Graded exercise versus Paced Exercise

Martin Westby   (11 August 2002)

Risks of exercise therapy

Simon N Paul, Nick C Harvey, Richard M Ellis   (16 August 2002)

Misleading presentation of results

Alan M Edwards, Kathy Longley, Robert Bennett, Norman Farron, Moira Henderson, Kim Lawson, and Marcus Vaz.   (7 September 2002)

Does 35% Really Prove Your Point?

N. Danielle Souder, n/a   (17 June 2003)

Re: The Findings of Selwyn, et al., May Be Due to Increased DHEA

jane L Barratt   (3 June 2005)

Magnesium repletion, not DHEA, for treatment of fibromyalgia

Ellen C G Grant   (5 June 2005)

The Findings of Selwyn, et al., May Be Due to Increased DHEA 27 July 2002
James M. Howard 1037 North Woolsey Avenue, Fayetteville, Arkansas 72701-2046,U.S.A. Send response to journal: Re: The Findings of Selwyn, et al., May Be Due to Increased DHEA	Selwyn, et al., found that exercise ameliorates symptoms of fibromyalgia. This may be due to increased DHEA. DHEA is low in fibromyalgia (Pain 1999 Nov;83(2):313-9) and exercise increases DHEA (Eur J Appl Physiol Occup Physiol 1998 Oct;78(5):466-71). To paraphrase Selwyn, et al., "[DHEA could be] a simple, cheap, effective, and potentially widely available treatment for fibromyalgia."
Our experience with fibromyalgia 28 July 2002
Shiju Majeed, Postgraduate student in orthopedics Medical College Trivandrum , India 695011 Send response to journal: Re: Our experience with fibromyalgia	Occasionally, patients with fibromyalgia present to our faculty. These are mostly patients who have been wrongly diagnosed to have some vague pain or mental disorders. We have found that infiltration of local steroids with local anaesthetics can considerably increase their well being in addition to graded aerobic exercises. Some of these patients are prescribed yoga and they do well
Fibromyalgia put on the front page 30 July 2002
Martin Westby, director 7 Ashbourne Road, Bournemouth, Dorset, BH5 2JS Send response to journal: Re: Fibromyalgia put on the front page	Dear Editor, I applaud the BMJ not just for publishing Richards and Scott’s paper on the treatment of Fibromyalgia, but also for putting it on your front cover. Fibromyalgia is still seen by some doctors as a non-disease, and many sufferers are denied adequate treatment and support. Treatment options are limited, but successive studies have shown that a graded exercise program, combined with an element of CBT, can greatly reduce disability. Long-term studies are still lacking, but with the advent of “exercise prescription” schemes and healthy living centres, there is some hope that effective interventions may be offered to more of the 1 to 2% of the population who suffer from this condition. Our website works with local groups to support sufferers and has been publishing a self-help exercise guide for some time. We have also been lobbying the government to achieve a higher profile for the condition, and more funds for research. Thank you for raising the profile for Fibromyalgia. We hope that through your intervention, more doctors will be able to adequately treat and support their patients in the future. Yours truly, Martin Westby
Missing data and compliance with oversimplification 1 August 2002
A Chaudhuri, Clinical Senior Lecturer in Neurology University of Glasgow Send response to journal: Re: Missing data and compliance with oversimplification	Prescribing exercise for fibromyalgia is a tempting option, and the BMJ's cover picture offers an example of exercise that surely many would wish to undertake. There are a few points though that may be worth noting. Firstly, the study recruited patients diagnosed between January 1997 and June 1998 but when published three years after the study was finished, it did not offer any data on the follow up period beyond the first year. Secondly, the authors did not provide any explanation as to why the comparative benefit of graded exercise is largely limited to the improvement in the quality of life questionnaire responses and did not influence McGill pain score, fibromyalgia impact questionnaires or fatigue severity. I would hesitate to accept an improvement in "tender point" counts as of much relevance because there is controversy regarding the nature of these pressure points and the validity of methods used to elicit them, and of course,mechanical dolorimetry suggests that these patients have a reduced tolerance of pain at all sites. Thirdly, given the fact that over two thirds of patients in each of the arms (48 and 47) fulfilled the full definition of chronic fatigue syndrome (CFS), I fail to understand why the authors have not provided us with any data on this important subgroup in terms of their outcome measures. I am also surprised why the data on fatigue measures in the two groups were not even presented in the paper given the fact that CFS and fibromyalgia are considered to be overlap disorders. Was this because graded exercise (as compared to relaxation) was not particularly effective for fatigue and the authors were instructed not to give importance to the fatigue outcome in this study since it would undermine the precriptions of graded exercise for CFS frequently advocated by the BMJ in the past year? Fourthly, there is almost an over-reiteration of fibromyalgia as a "medically unexplained symptom". In reality, fibromyalgia does not represent a single symptom and authors should have taken note of an authoratitive text before submitting to this naive paradigm.[1] Finally, it has been suggested that cognitive behaviour therapy(CBT) would improve patient's compliance to graded exercise. This is a new and untested hypothesis. Having done a post-doctoral thesis some time ago on patient compliance to long term anti-epileptic drug therapy,I have some reservations in accepting that compliance to "prescriptions" would be specifically enhanced by CBT over and above other measures.Infact, the term "compliance" itself is very contentious since it is defined as the extent to which a patient's behaviour coincides with the doctor's advice. Thus, the term compliance, even when used in the context of medical therapy, has been objected to as having overtones of obsolete, arrogant attitudes, implying obedience to the doctor's orders [2]. The suggested alternative is adherence. Whilst no one would question that physical exercise improves quality of life both in health and diseases in general, recommending graded exercise as a specific prescription for complex disorders like fibromyalgia and CFS is a gross oversimplication of science. The BMJ headlines of graded exercise in fibromyalgia and CFS however keep reminding me of an old text that I had come across sometime back in an antique book shop. This book was written by Frenkel who was the medical superintendent of the Freihoff Sanatorium in Switzerland and one of the first to recommend extensive physiotherapy for neurologic diseases with his introduction of exercises for tabetic ataxia in 1890. Frenkel's book ("The treatment of tabetic ataxia by means of systematic exercise") suggest to me that learning history is as important as precribing exercises even if we are treating only the "non-diseases". Last but not the least,I hugely appreciate the efforts of the authors in researching this difficult area. References 1. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins 2001. 2. Lawrence DR, Bennet PN. Clinical Pharmacology. Edinburgh: Churchill Livingstone 1987.
Further Discomforts of Patient Power. 7 August 2002
Horace Reid, Patient with CFS Co. Down Send response to journal: Re: Further Discomforts of Patient Power.	Trials of graded exercise and cognitive therapy for the fatigue syndromes have a dreary predictability. The sample will be small, the investigators will play ducks and drakes with the inclusion criteria, the outcome measures will depend on self-report, with insufficient objective corroboration. There will be a high attrition rate among the participants, necessitating an intention-to-treat analysis.[1] There will be no report of adverse events, despite frequent complaints from patients.[2] The authors will claim that their therapy is "effective", meaning anything or nothing. When the project begins to ship water, blame is subtly transferred from investigators to participants. Many of these deficiencies were identified in a recent JAMA systematic review on CFS trials,[3] despite which a number are replicated in this King's-inspired paper[4] on the allied condition of fibromyalgia. The authors acknowledge "high dropout rates". Less than 28% of patients attended all the exercise sessions offered and 16% attended none. A 30% attrition rate was anticipated, but the flow chart suggests that patient absence from exercise treatment averaged 55%. When formulating their protocol, the rheumatologists were advised by Professor Simon Wessely's associates in King's College department of Psychological Medicine. Chronic fatigue syndrome overlaps fibromyalgia, and 70% of patients in this trial satisfied CFS criteria. In 2000 one well-conducted survey found that 12.9% of CFS patients received major benefit from graded exercise, but 38.8% found it harmful.[2] Wessely now admits the limited efficacy of this form of therapy,[5] though he has yet to confide this insight to the readership of the BMJ. The high drop out rates in some CFS trials have been identified as a phenomenon in its own right. The JAMA reviewers queried whether dropouts might be attributed to "adverse effects arising from the intervention". In this latest paper, the authors say they "did not record any adverse events in either group". Statistics for those who felt worse or very much worse were recorded, but are not published. It is not clear whether drop-out patients were actively surveyed for evidence of harm. It seems that dropouts did find that "exercise worsens the condition." The authors propose that future trials "confront the issue of compliance", by subjecting patients to cognitive behavioural therapy. Possibly this initiative too was suggested by Professor Wessely's department. Six months ago, Wessely announced a new era of amity between patients and physicians, in the management of CFS.[6] In this context the authors' choice of words is unfortunate, and the implications are perturbing. Many patients did not share the authors' enthusiasm for graded exercise. Large numbers exited the trial for that reason, the study suggests.[7] The authors' response is that in future investigations, therapists should systematically challenge the individual intelligence and collective judgement of those patients who choose to withdraw. A recent BMJ editorial implied that such an approach should not be contemplated, especially where CFS patients are concerned.[8] But Richards & Scott are oblivious to warning voices, and cognitive behavioural therapists are to be drafted in. Their role, it appears, will be to erase the validity of the patients' experience, and to substitute the comfortable perception that doctor knows best. Ah, if only all clinical trials might be conducted this way. ========= 1 cf Prins JB et al, Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial, Lancet Vol 357 841-47, March 17 2001. This trial had significantly higher dropout rates in the CBT group (40%) than in the support group (32%) or control group (20%). Of 377 eligible patients, 99 (26%) refused to participate from the beginning. 2 Cooper L, Report on Survey of Local ME Groups, pp 19 & 20. (Action for ME and the ME Association, 2000). Accessed 21 May 2001 at http://www.meassociation.org.uk/locgrsur.pdf 3 Whiting P et al, Interventions for the Treatment and Management of Chronic Fatigue Syndrome - A Systematic Review, JAMA 2001 Vol. 286, #11, pp. 1360-1368. 4 Richards SCM, Scott DL, Prescribed exercise in people with fibromyalgia, BMJ 2002;325:185 ( 27 July). 5 GET and CBT are only "modestly effective", he says, and "not remotely curative"- Wessely S, Chronic Fatigue Syndrome - Trials and Tribulations, JAMA Vol. 286, #11, September 19, 2001. 6 Clark C, Wessely S et al, Chronic fatigue syndrome: a step towards agreement, Lancet Vol 359 no 9301, 12 January 2002. 7 cf "Chronic fatigue syndrome, Clinical practice guidelines 2002", (Working Group, Royal Australasian College of Physicians), MJA 6 May 2002 176 (8 Suppl): S17-S55. - "many studies have significant refusal and drop-out rates, which may reflect on the acceptability of the treatment regimens. These factors significantly limit the generalisability of the findings." 8 "Views of patients are certainly beginning to prevail with chronic fatigue syndrome" - Smith R, The discomfort of patient power, BMJ 2002;324:497.
Fibromyalgia needs pragmatism 9 August 2002
Joe McVeigh, Lecturer/Practitioner in Physiotherapy University of Ulster, Belfast, BT 37 0QB Send response to journal: Re: Fibromyalgia needs pragmatism	Dear editor While congratulating Richards and Scott for their report on the effectiveness of a commonly used treatment intervention for fibromyalgia patients [1]. I feel their paper suffers from the same failing they identify in other work i.e. the generalisability of results. It is known that patient with fibromyalgia commonly feature on physiotherapists’ caseloads [2], however, I venture that few fibromyalgia patients in the NHS have access to personal trainers providing individual exercise regimes. I submit, therefore, that this limits the extent to which Richards' and Scott's results can be generalised to the broad population of fibromyalgia suffers receiving treatment in the NHS. Indeed our own work has revealed that published trials investigating exercise intervention in fibromyalgia generally involved more prolonged treatment intervention than is the case in clinical practice. I respectfully suggest that future research should focus on pragmatic randomised controlled trails evaluating what is current practice in the NHS for fibromyalgia sufferers. 1. Richards SCM, Scott DL. Prescribed exercise in people fibromyalgia: parallel group randomised controlled trail. BMJ 2002; 325: 185-187. 2. McVeigh J, Archer S, Hurley DA, Baxter GD, Basford JR. Physiotherapy management of fibromyalgia syndrome: survey of current practice in Northern Ireland. Physiotherapy 2002; 88: 435-436. Mr. J McVeigh Lecturer/Practitioner in physiotherapy University of Ulster and Royal Group of Hospitals Trust, Belfast, Northern Ireland j.mcveigh@ulst.ac.uk
Graded exercise versus Paced Exercise 11 August 2002
Martin Westby Send response to journal: Re: Graded exercise versus Paced Exercise	Horace Reid speaks about the high attrition rate, which has caused many people to drop out of the study All fibromyalgia sufferers talk about having good days followed by bad days and the very high drop out rates in this paper suggest that forcing a regime of graded exercise on fibromyalgia sufferers is less effective than making the exercise appropriate on a day by day basis. This is known as pacing. In January 2002 the Department of Health released a report from the working party for Chronic Fatigue and ME. Which discussed graded exercise versus pacing. Whilst these conditions are different from fibromyalgia there are a number of similarities in symptoms. One key controversy that exists over graded exercise rests on whether the nature of the treatment is appropriate for the nature of the disease, at least in some individuals. Existing concerns from voluntary organisations and some clinicians include the view that patients have a primary disease process that is not responsive to or could progress with graded exercise, and that some individuals are already functioning at or very near maximum levels of activity. A successful outcome probably depends on the therapy being initially based on current physical capacity, mutually agreed between the therapist and patient, and adapted according to the clinical response. Appropriate education regarding the rationale and cautions of this therapy needs to be given to potential candidates for graded exercise. Patients who drop out of therapy need to be followed up swiftly to review the reasons and reassess their management plan.
Risks of exercise therapy 16 August 2002
Simon N Paul, SpR Rheumatology & Rehabilitation Salisbury District Hospital, Salisbury, Wiltshire. SP2 8BJ, Nick C Harvey, Richard M Ellis Send response to journal: Re: Risks of exercise therapy	EDITOR - We read with interest the paper by Richards et al, which suggests that incremental exercise provides an effective intervention for fibromyalgia, compared to relaxation strategies.1 Previous studies have suggested that exercise has been found to be an effective short term strategy for the management of this chronic condition.2 However, there are concerns over the methodological quality of some of these studies. Different regimens and duration of intervention and follow up mean that many of these studies are not directly comparable. However, the common theme in many of the studies is poor compliance. What is not clear from the discussion by Richards et al 1 is whether a warming up programme was used in the exercising group. Also, no mention is made of whether or not exercise related injuries were sustained during the 12-week intervention. Warming up is known to reduce muscle stiffness and may reduce the severity and subsequent symptoms of muscle damage in healthy subjects. 3 Taurine supplementation and depletion, and prednisolone have been investigated in animal models in an attempt to limit the oxidative and mechanical stress, which is thought to lead to muscle fibre damage 4,5 . Impairment in the action of transport proteins for glucose and lactate has also been implicated in the increase in muscle stiffness following unaccustomed exercise. We believe that it is essential that all physicians prescribing graded exercise therapy (which may be conducted within National Lottery funded Healthy Living Centres) should explain the risks and potential side effects of this treatment. We also feel that compliance with graded exercise programmes could be improved if we can find suitable treatments for exercise induced muscle stiffness and soreness. [END] Simon N Paul, Specialist Registrar in Rheumatology and Rehabilitation Nick C Harvey, Specialist Registrar in Rheumatology Richard M Ellis, Consultant in Rheumatology and Rehabilitation Department of Rheumatology, Salisbury District Hospital, Salisbury, Wiltshire. SP2 8BJ. Email : dr.paul@salisbury.nhs.uk References. 1. Richards S, Scott D L. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ 2002; 325: 185-187. 2. Offenbächer M, Stucki G. Physical therapy in the treament of fibromyalgia. Scand J Rheumatol 2000; 29 Suppl 113:78-85 3. McHugh M. Br J Sports Med 1999:33: 377 4. Dawson Jr R, Biasetti M, Messina S, Dominy J. Amin Acids 2002:22(4):309 -24 5. Jacobs SC, Bootsma AL, Willems PW, Bar PR, Wokke JH. J Neurol 1996:243(5):410-6
Misleading presentation of results 7 September 2002
Alan M Edwards, Clinical Assistant The David Hide Asthma and Allergy Research Centre, St. Mary's Hospital, Newport, Isle of Wight. PO30, Kathy Longley, Robert Bennett, Norman Farron, Moira Henderson, Kim Lawson, and Marcus Vaz. Send response to journal: Re: Misleading presentation of results	Editor—We welcome the prominence given to the article on the use of exercise therapy in fibromyalgia by Richards and Scott (1), but have some concerns over the way the results may be interpreted. The outer cover of the journal featured the picture of a swimming woman with the underlying headline, “Prescribing exercise for fibromyalgia - simple, cheap, and effective. We suggest that this is misleading. Swimming was not part of the exercise programme described in the article and there is no evidence that swimming is beneficial in this condition. The actual exercise programme was “an individualised aerobic exercise programme, mostly walking on treadmills and cycling on exercise bicycles”. Individualised programmes involving expensive equipment are neither simple nor cheap. The use of the term “effective” should be qualified. The primary outcome measure, change in self rated global impression, although statistically in favour of the exercise treatment group, resulted in only 35% of those randomised to this intervention being classified as responders. Also only 19 of the 69 subjects randomised to the exercise treatment were able to complete more than two-thirds of the twice weekly classes. In absolute terms this treatment could be described as useful for some patients but not effective for all. Regarding the secondary outcome measures: the changes in the Fibromyalgia Impact Questionnaire (FIQ) showed deterioration in the FIQ at 3 months, a 7% improvement at 6 months and a 4% improvement at 1 year. These latter 2 results were statistically significant but do not represent a clinically meaningful improvement. Details of the existing medications, which participants continued at entry were not provided. If there was a difference in the medications being taken by the groups who found the exercise intervention effective, ineffective or who failed to complete the course, this might mean that the effectiveness of the exercise was due to support from the drug treatments. It is therefore inappropriate to isolate the exercise programme as being responsible alone for the improvement found by some patients. Despite these reservations we believe that this study does provide evidence of the benefits of exercise for this difficult to treat condition, as have several previous studies (2). Fibromyalgia is very heterogeneous in its severity and for many patients exercise needs to be incorporated into a multidimensional management programme, as recently highlighted in the May 2002 edition of the Rheumatic Disease Clinics of North America entitled the “Rational Management of Fibromyalgia” (3, 4,). We are concerned that that the way this study was presented may encourage some doctors to dismiss patients with the words “go and take more exercise”, without considering the complexity of the problems in those with severe symptomatology. Exercise is of benefit in most chronic disorders, but more is not always better. Indeed there are negative aspects of too much exercise done too soon (5). It is to the credit of the Richard and Scott study that the intensity of exercise was individualized each subject and started out a gentle pace. Kathy Longley, Co-ordinator, Medical Advisory Board, Fibromyalgia Association UK, 41, Wedmore Park Southdown Bath. BA2 1JZ UK Robert Bennett, MD, FRCP Professor of Medicine, Oregon Health & Science University, Portland, Oregon, USA Alan Edwards, Clinical Assistant * The David Hide Asthma and Allergy Research Centre St Mary’s Hospital Newport. Isle of Wight. PO30 5TG UK Norman Farron, Biomedical Scientist 239 Down Road Portshead Bristol BS20 8HU UK Moira Henderson, Medical Adviser for the Department of Work and Pensions Department of Work and Pensions The Adelphi 1-11 John Adam Street London. WC2N 6HT UK Kim Lawson, Senior Lecturer in Pharmacology Division of Biomedical Sciences Sheffield Hallam University City Campus Sheffield. S1 1WB UK Marcus Vaz, Registered Osteopath 2 Marfleet Close Lower Earley Reading Berks. UK Members, Medical Advisory Board, Fibromyalgia Association UK. References 1. Richards SC, Scott DL. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ 2002; 325(7357):185. 2. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome (Cochrane Review). Cochrane Database Syst Rev 2002;(3):CD003786. 3. Bennett RM. The rational management of fibromyalgia patients. Rheum Dis Clin North Am 2002; 28(2):181-99, 4. Littlejohn GO, Walker J. A realistic approach to managing patients with fibromyalgia. Curr Rheumatol Rep 2002; 4(4):286-292. 5. Jones KD, Clark SR. Individualizing the exercise prescription for persons with fibromyalgia. Rheum Dis Clin North Am 2002; 28(2):419-436
Does 35% Really Prove Your Point? 17 June 2003
N. Danielle Souder, ? disabled due to FM, n/a Send response to journal: Re: Does 35% Really Prove Your Point?	I apparently have had fibromyalgia for 25-30 years. I have tried MANY medications. I have tried FOUR exercise programs. Three of these exercise programs were supervised. Each resulted in not only a SEVERE "flare up" but a permanent and OVERALL worsening of the condition. I have only spoken with one person who has had relief from regular exercise; the exercise is Yoga and she is in the "early stages" of the illness. I have spoken to untold numbers of other sufferers who experienced the same results as I have with exercise programs. One of whom was formerly an aerobics instructor! Even without ALL the details of the study I still question the claims made by the researchers and the misleading interpretation of the results-- the actual statistics of which are rarely mentioned. Another issue is that the medical community still does not seem to recognize that fibromyalgia is a progressive illness. There ARE stages. Over the last 25-30 years I had to progressively lessen my working hours and responsibilities; despite the fact that I was my sole support and was a single parent. The longer this misinformation (that "Exercise Helps Fibromyalgia") is perpetuated, the long it will be until there is real and actual progress made in relieving, and possibly curing, its sufferers. Researchers especially should not have preconcieved notions and go into a study to "prove" a point. They should be looking for REAL results. Competing interests:   None declared
Re: The Findings of Selwyn, et al., May Be Due to Increased DHEA 3 June 2005
jane L Barratt, Full time mother NW3 2LE Send response to journal: Re: Re: The Findings of Selwyn, et al., May Be Due to Increased DHEA	Dear Sirs, I am an expert patient, who has had the misfortune to have suffered the torture of FMS/CFS for 5 years after the birth of my second son. The previous six years I had pain in my hips and was extremely tired from the birth and my job as full time mum of my first lively, sleepless son. I have fully recovered extremely quickly. Less than 6 months of skilful physiotherapy and sports medicine. I thought you might be interested to know that FMS/CFS is progressive and therefore preventable. Had I been treated by a competent physiotherapist or indeed been referred to a competent physiotherapist within the NHS. I guess I wasn't, even after the birth of my children, because of who I am. I have a physical report by the private physiotherapist who has given me my life back. 1. An unstable right sacroiliac joint 2. Poor gluteal control in stance phase 3. A dynamic flexion-extension shear at l3 4. Sway back posture 5. Hypomobile anterior hips structures and thoracolumbar junction 6 Right anterior palpation of C6 reproduced headache. He goes on to say;- My working hypothesis was based upon physical findings, which explained the multi focal pain. The initial injury caused a compensatory internal rotation of her right leg. Over a period of time, the altered mechanics and decreased shock absorbency causes the right sacroiliac joint to become functionally unstable. The secondary changes include the hypomobility to the anterior hip and thoracic spine. The forward sitting head posture can be related to the thoracic spine stiffness and poor spinal patterns of movement. Manual therapy was directed to the stiff, hypomobile segments, whilst a progressive, functional and tailored rehab program was implemented to enable Ms Barratt to move correctly in a pain free fashion. He goes on to say that I have a well controlled diet and maintain an adequate level of fitness. He also says, I see no reason why Ms Barratt should not have a normal and pain free life with minimal levels of rehabilitative exercise and care. As you will see, his physical report acknowledges the WHO's definition of Fibromyalgia as musculo/skeletal. I do not believe that FMS is a disease, it is a mechanical problem, that causes CFS. A senior clinical physiotherapist, within the musculo/skeletal rhuematology department at my local hospital, two years previously gave her analysis, as 'postural due to stress'. And we all know where this led me to within the NHS. Had the head of pain clinic not forgotten to follow up my appointment with him, he would have sent me to see a psychiatrist! I am hoping that someday soon, GP's will be educated and Sports Medicine will be widely available within the NHS. The combination of physical injury, trauma and infection for elite athletes, such as Kelly Holmes and Paula Radcliffe is the cocktail that produces the various diagnosis's of Athletes Overtraining syndrome, Underperformance syndrome, Under recovery syndrome and CFS. Rheumatologists, it seems to me, suffer from their own professional policies. The combination of physical injury, trauma and infection could be used as a model for prevention of FMS/CFS. How is this going to be done? I am also a Patient and Public Involvement forum member for [don't laugh] Camden and Islington Mental Health and Social Care Trust, however as I have not told my fellow forum members that I am writing to you, I do not have this hat on at the moment. with best regards Jane Barratt janebarratt@talktalk.net Competing interests: None declared
Magnesium repletion, not DHEA, for treatment of fibromyalgia 5 June 2005
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK Send response to journal: Re: Magnesium repletion, not DHEA, for treatment of fibromyalgia	Selwyn and colleagues describe graded aerobic exercise as a simple, cheap, effective, and available treatment for fibromyalgia.1 It has been suggested that because dehydroepiandrosterone (DHEA) levels have been found to be low in the condition and raised by exercise, DHEA supplements can be used. However, DHEA supplements may increase the risk of breast cancer in postmenopausal women. A reanalysis of nine prospective studies found strong evidence that in postmenopausal women the levels of the predominant endogenous sex hormones, oestrogens and androgens, are strongly associated with breast cancer risk. The risk for breast cancer increased statistically significantly with increasing concentrations of all sex hormones examined: total estradiol, free estradiol, non-sex hormone-binding globulin (SHBG)- bound estradiol (which comprises free and albumin-bound estradiol), estrone, estrone sulfate, androstenedione, DHEA, DHEA sulphate, and testosterone.2 Missmer and colleagues also found higher median levels of plasma oestrogens and androgens, including DHEA and DHEA sulphate postmenopausal women with breast cancer than in controls.3 The increased relative risks (RRs) of ER+/PR+ tumours in women with highest levels of hormones were 3.3 for oestradiol; 2.0 for testosterone; 2.5 for androstenedione; 1.6 (0.9 to 2.7) for DHEA and 2.3 (1.3 to 4.1) for DHEA sulphate. About a third of the postmenopausal women had no detectable amounts of progesterone or had plasma levels ranging from 1.5 to 10 ng/dL. In contrast, DHEA levels ranged from 169 to 536 ng/dL. Patients with fibromyalgia have significantly lower levels of magnesium in erythrocytes but not in serum. For a 100 patients the mean RBC Mg was 1.92 mmol/L compared with 2.3 mmol/L in the reference population. 4 Low red cell magnesium levels relate to irregular muscle activity in myothermograms and over-exercise can cause muscle damage unless magnesium deficiencies are repleted.5 In contrast to steroid hormones, magnesium supplements are a safe and an essential treatment for fibromyalgia. 1 Selwyn C M Richards and David L Scott. Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ 2002; 325: 185 2 The Endogenous Hormones and Breast Cancer Collaborative Group. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst 2002; 94: 606- 16. 3 Missmer SA, Eliassen H, Barbiera RL, Hankinson SE. Endogenouis estrogen, androgen, and progesterone concentrations and breast cancer risk among postmenopausal women. J Natl Cancer inst 2004:94: 1856 -65. 4 Romano TJ, Stiller JW. Magnesium deficiency in fibromyalgia syndrome. J Nutr Med 1994; 2: 165-167. 5 Howard JMH. Muscle action, trace elements and related nutrients: The Myothermogram. In: Chazot G, Abdulla M, Arnaud P, eds. Current trends in Trace Element Research: Proceedings of International Symposium on Trace Elements. Paris, 1987, Smith-Gordon, London 1989:79-85. Competing interests: None declared