by Moira Smith
April 1999, with updates
[ Introduction ] [ The
diagnostic criteria ] [ Comparing symptoms ] [ Expert opinions ]
[ One, two, many ] [ What's in a name?
] [ Conclusion ] [ Further reading ] [ References
]
Postscript 2002: Some recent research findings
that may show what the difference is
I write this not as an expert, but as a person who was first diagnosed with Fibromyalgia Syndrome, and then after a further deterioration in my health realised my symptoms now also fit the definition of Chronic Fatigue Syndrome. I began to wonder if I had two diseases, or if this was one disease with two names. I was aware that the experts themselves differed on this topic; every article I read seemed to say something different.
To add to the confusion, I knew others with a dual diagnosis: some had progressed from FMS to CFS, as I had, while others had begun as CFS patients and had been diagnosed with FMS later. One Fibromyalgia patient told me she had had a year-long episode of CFS following an infection.
I decided to do some research to clarify the situation in my own mind; and this article is the result. In the first part, I take a fairly typical description of FMS and compare it with a fairly typical description of CFS, to see for myself where the similarities and differences lie. The second part of this article is a series of quotes from various expert doctors and researchers, illustrating different points of view on the relationship between CFS and FMS. Finally, I attempt to come to a conclusion.
[ Contents ]
The diagnostic criteria for both syndromes leave much to be desired.
CFS is also known as ME for "myalgic encephalitis" ( a name reflecting the common combination of muscle pain and neurological symptoms) and, in the USA, "Chronic Fatigue and Immune Dysfunction Syndrome" or CFIDS. The standard diagnostic criteria in use today are contained in the 1994 "revised case definition" (Fukuda et al) used by the USA Government Center for Disease Control (CDC) in Atlanta [1].
The CDC's original 1988 case definition (Holmes, et al), framed in response to the 1984 Lake Tahoe outbreak of an apparently new and infectious illness, was designed not for diagnostic purposes but for choosing subjects for research studies [2]. However, less than ten percent of those first Lake Tahoe patients actually fitted the definition [3]. Many who probably had the illness were left out, and this may even have hampered research.
It was also at that stage that the "F word" - fatigue - so hated by sufferers, became irrevocably connected with the illness. The CDC officials who visited Lake Tahoe, faced with the multiplicity of symptoms being reported by the patients, decided to pick out one common denominator to work with: "Everyone says they’re tired. Okay. Let’s used tiredness as a definition" [4].
The second, revised, case definition was supposed to correct the problems of the first one, but it is still not ideal as a diagnostic tool. For instance, we now know that not all cases of CFS appear as part of an infectious outbreak; yet "gradual onset" cases, which don’t start with an infection, still don’t quite fit the new definition. People have to have been sick for at least six months before they can be diagnosed with CFS, and anyone who also suffers from another disease is excluded. These safeguards are necessary when choosing subjects for research studies, but they are not useful when making an initial diagnosis.
A brief summary of the CDC CFS Case Definition:
1. Fatigue of new onset that limits activities.
2. Four or more of the following: memory or concentration problems, sore throat, tender lymph nodes, muscle and/or joint pain, new type headaches, unrefreshing sleep, and feeling ill for more than a day after effort.Conditions that exclude a diagnosis of CFS:
1. Any other current illness that causes fatigue, or medicine side-effects.
2. Any past illness causing fatigue that might not have completely gone away.
3. Past or current psychiatric disorders such as depression "with psychotic or melancholic features", bipolar, schizophrenia, anorexia or bulimia.
4. Alcohol or drug abuse within last 2 years.
5. Severe obesity.
Conditions that do not exclude a diagnosis of CFS include: Fibromyalgia, anxiety, nonpsychotic or melancholic depression, neurasthenia, and multiple chemical sensitivity disorder.
Although the people who fit the CFS criteria do have much in common - including, of course, fatigue - they may also have many other sorts of symptoms, and can vary a great deal. As Dr Hugh Dunstan of Newcastle University’s Collaborative Pain Research Unit told the Sydney CFS Conference in February 1998, this makes CFS patients "very difficult to study clinically and scientifically" [5].
The generally accepted diagnostic criteria for FMS, from the American College of Rheumatology [6], seem simple: 11 out of 18 designated "tender points", and widespread pain (both sides of the body, above and below the waist, and must include the spine) for at least three months.
The discovery of the Fibromyalgia tender points was originally welcomed by doctors and patients alike. An objective sign that could be observed by the doctor, rather than a symptom reported by the patient, they proved that FMS was real and not "all in the head". Also, because they are not in the places where FMS aches and pains are normally felt, most sufferers would have been unfamiliar with them (though this is probably no longer true). So if you said "ouch!" when the doctor pressed a tender point, and not when he pressed somewhere else, he could tell you were not faking. One problem with this idea is that, as FMS sufferers know, it doesn't really matter where you prod us, it will hurt!
Unfortunately the tender points are often confused with the myofascial "trigger points" that cause pain in so many people with FMS. Trigger points can be almost anywhere on the body and, unlike tender points, can refer pain elsewhere, as well as causing other symptoms [7].
It is now recognised that the use of tender points for diagnosing FMS is problematic [8]. They tend to come and go, and the number eleven seems arbitrary. If a person only has ten tender points instead of 11, but has other FMS symptoms, does she have FMS or not? I think it is true to say that most doctors diagnosing FMS today don’t count the tender points, but make the diagnosis on the basis of the total clinical picture - that is, irritable bowel, sleeplessness and other symptoms together with "widespread pain and tenderness". This reflects the nature of FMS more accurately.
[ Contents ]
Because the diagnostic criteria for FMS and CFS are measuring different things, it is possible to meet the criteria for both disorders, and in fact many people do. Does that mean that some of us are unfortunate enough to have two different diseases?
As doctors are so fond of telling us, FMS and CFS are syndromes, not diseases. They are collections of symptoms of unknown cause, that are often found together. It is becoming increasingly apparent that CFS and FMS overlap too much to really be clearly distinguished from each other, at this stage of our knowledge. Whether a person is diagnosed with one or the other often seems to depends more on their GP’s preference, or which specialist they are referred to, than on any difference in symptoms. Rheumatologists, for example, diagnose fibromyalgia where there is muscle pain and fatigue, while another specialist might diagnose CFS.
I decided to do a mini-experiment and find out for myself how much the symptoms of CFS and FMS overlap. I picked two articles from the World Wide Web that contain lists of symptoms: the first is The most common symptoms of Fibromyalgia by Bruce Massau, M.D. [9]; and the second is Dr. Jay Goldstein's CFIDS Symptom Checklist [10].
I chose them because they both have comprehensive lists, and include a wide range of "optional" symptoms as well as the major ones that most people have. I compared the main symptoms first. The figures are the proportion of sufferers said in each article to have each symptom:
| SYMPTOM | FMS | CFS |
| muscle pain | 100% | 75% |
| fatigue | 65% | 100% |
| sleep problems | 95% | up to 100% |
| cognitive problems | 40% | 80% |
| irritable bowel | 40% | 50% |
These figures are, of course, "guesstimates", and are slightly different in every article you read. In particular, I have often seen the pain score for CFS patients put as low as 50 - 60%, and irritable bowel is normally said to be more common than 40% in FMS. (In fact it is often named as one of "the symptoms" of FMS - implying that nearly all patients have it.) As for cognitive problems, although Massau puts the figure for FMS sufferers at only 40%, one only has to read the internet discussion groups, or talk to fellow sufferers, to suspect that "fibro-fog" is much commoner than that.
However, the exact figures are not important. What I am trying to point out is that, except for all CFS patients having fatigue with most having pain, and all FMS patients having pain with most having fatigue, there is not much difference.
Next I picked out all the other symptoms and conditions that were listed in both papers. Here are most of them:
| severe headaches | anxiety/depression | thyroid problems |
| numbness/tingling | muscle twitches/spasms | irritable bladder |
| alcohol intolerance | light/noise sensitivity | night sweats |
| swollen glands | sore throat | low-grade fever |
| breathlessness | heart palpitations | TMJ (jaw problems) |
| chest pain | mitral valve prolapse | allergies & sensitivities |
| eyesight changes/problems | sicca syndrome (dry eyes/mouth) |
Amazingly, though terminology varied, I was not able to find one class of symptoms that was mentioned in one paper and not the other.
[ Contents ]
Opinions of experts vary as to the nature of the relationship between CFS and FMS. Some of the main suggestions are summarised below:
Leon Chaitow says: "The more the condition has been researched (FMS that is) the more obvious it has become that there is a vast overlap between it and ME/CFS." [11]
The increasingly popular concept of "overlapping syndromes" is a compromise, attempting to explain the similarity while maintaining the status quo that there are two syndromes. Actually it is descriptive rather than explanatory. According to this model, whether people suffer mainly from pain or fatigue (or both) as their main symptom, their illnesses are very similar. To quote Leon Chaitow again:
The only obvious difference seems to be that for some people the fatigue element is the most dominant while for others the muscular pain symptoms are greatest (and for an unfortunate few both are markedly present). In other words for many people the diagnosis CFS(ME) and FMS seem to be interchangeable terms, although there are certain symptoms (fever, swollen glands for example) which are found in a higher percentage of CFS(ME) patients than those with FMS.
The Wallaces, who agree with Chaitow that people with CFS have more "viral" symptoms like sore throat and swollen glands, remark helpfully that: "Comparative surveys show that 20-30 percent of fibromyalgia patients have CFS, and 35 percent of those with CFS have fibromyalgia." [12]
The FM Network is a prominent organisation in the USA that publishes a quarterly magazine valued for its up to date information. In every issue, it makes the statement that in its articles, the term "FMS" is to be taken as also including CFS, and vice versa. In articles on its website, the FM Network reports findings by Dedra Buchwald, Anthony Komaroff and Don Goldenberg "that CFS and FMS overlap in patients by as much as 75%" [13], and that a study by Dedra Buchwald found people who meet the criteria for both syndromes tend to be those more severely affected, and less able to work [14].
Dr Muhammad Yunus, the pioneer Fibromyalgia researcher, has proposed that Fibromyalgia is only one of a whole group of overlapping and similar ailments that seem mostly to afflict women. As with FMS, the symptoms include pain, fatigue and poor sleep; and there seems to be something wrong with the brain’s neurotransmitters and the production of hormones by the hypothalamus, pituitary, and adrenal glands (the "HPA axis" we often hear about in connection with FMS research). Yunus calls this model the “Dysregulation Spectrum Syndrome”. It includes not only both FMS and CFS, but also irritable bowel syndrome, tension headaches, migraine, myofascial pain syndrome, temporomandibular joint pain (TMJ), restless legs syndrome, and primary dysmenorrhea (painful periods not caused by a gynaecological problem) [15].
Dr Mark Pellegrino, author of “The Fibromyalgia Survivor” and other popular books, acknowledges that: “CFS is a condition which many physicians feel is very similar to Fibromyalgia. In fact many medical professionals feel that the two “names” are actually the same condition” [16]. However, he feels that “Chronic fatigue syndrome may be a subset of a broader Fibromyalgia syndrome” - in other words, he sees CFS as a special kind of FMS.
Dr Daniel Malone, a rheumatologist at the University of Wisconsin Hospital, agrees that despite the fact that CFS and FMS have very different definitions (as we saw earlier), “the two conditions are probably more similar than they are different." But he also sees a difference in CFS patients:
In my experience with about 300 patients, the main differences appear to be that chronic fatigue syndrome patients have fatigue as a more disabling or prominent symptom. They appear to have more immune dysfunction as evidenced by frequent infections, fever and swollen lymph nodes ... Other than that, the two conditions are quite similar. [17]
In contrast, Erich D. Ryll, M.D. sees the joint and muscle pain of FMS as a symptom of CFS:
Generally, if you are seen by a rheumatologist or internist, he or she may say that you have Fibromyalgia. And indeed you have Fibromyalgia. But it is one facet, one part of your illness, the chronic fatigue syndrome. I have examined 5000 of you at this time, and all but about 8 have had the chronic fatigue syndrome . . . . In other words, Fibromyalgia is just one part of your disease. Some of you have it mildly, some of you, severely. Generally I believe that those who label this disease Fibromyalgia are akin to the seven blind men with the elephant; they only see the trunk or the tail - and miss all the rest that is going on with you. [18]
E.M. Goudsmit is a British researcher who might be called a “splitter” rather than a “lumper”. She is part of a movement in the UK that is pushing for the recognition of Myalgic Encephalomyelitis (ME) as a disease in its own right, not just an alternative name for CFS. So it is hardly surprising that she also sees Fibromyalgia as entirely different:
CFS(ME) patients may report areas of muscle tenderness similar to those documented in Fibromyalgia. However, the latter more often has a gradual onset, morning stiffness is a more prominent symptom, fatigue tends to be worse early in the day, and there are generally fewer signs of ongoing infection ... Fibromyalgia is also more common than CFS, affecting an estimated 2-4% of the population at large ... While further clarification is clearly required, the consensus of opinion seems to be that the two conditions share certain similarities, but that they are not one and the same ...[19]
Dr Gouldsmit is generally correct about the differences - but one could argue that they are not as significant as the similarities. She is also, as we have seen, wrong about the consensus of opinion being that they are not the same.
[ Contents ]
While the expert opinions presented here are all slightly different, what they have in common (excepting Gouldsmit) is an agreement that it is wrong to separate FMS and CFS completely, or to insist that they are two entirely different diseases.
However, that does not mean that the conclusion must be "they are one and the same". Indeed, as research progresses, it is becoming clearer that the very question, "is FMS the same as CFS" is over-simplistic. Professor Tim Roberts of the Newcastle University, summing up the Sydney CFS Conference 99 at which many prominent researchers were present, pointed out in that there is now "agreement that the umbrella term 'CFS' appears to cover a number of subgroups" - which may have completely different causes [20]. Following their analysis of large numbers of patients, the Newcastle Research Team find they are looking at about seven sub-types of what they call "polysymptomatic", "chronic pain/fatigue patients".
It is my hunch that the illness we call "Fibromyalgia" will turn out to span maybe 2 or 3 of these subgroups. For there seem to be different types of FMS too. Some people get sick suddenly, after an infectious illness, accident or injury; other cases are "slow onset", sometimes beginning in childhood, and seem to run in the family. Some cases are relatively mild while others cause severe disability. Some have the immune-activation symptoms (swollen glands, "fluey" feelings) that are often the hallmark of CFS, while others do not. Research into the subgroups of CFS could explain these differences, and the types of FMS could be renamed according to their cause and particular characteristics.
[ Contents ]
That is for the future. Currently, people whose main problem is muscle pain are usually referred by their GPs to a rheumatologist, leading to a diagnosis of "Fibromyalgia". For people whose problem seems to have started with an infectious disease, or who have a sore throat, swollen lymph nodes and/or rashes, the road to diagnosis tends to be less direct and is by way of terms like "postviral fatigue syndrome" and "allergy" to CFS. Often as a patient's condition worsens and additional symptoms appear they gain the dubious distinction of a dual diagnosis.
Does it matter one way or another what name your doctor gives your illness? I think the answer is "yes". I think the name "Fibromyalgia" affects how our illness is viewed, and the treatment we are offered, often to our disadvantage. In particular, I believe that the seriousness of Fibromyalgia, and the pain and disability it can cause, are often downplayed. FMS is usually portrayed as a non-progressive, fairly mild condition that can be "managed" as long as the patient has information and self-discipline. This view, which in my opinion does not apply to the majority of cases, is not only held by doctors, but also by some FMS self-help book authors who relate how they live active and practically normal lives despite the disease [21].
The central features of Fibromyalgia are usually considered to be the characteristic sleep disturbance, irritable bowel problems and, of course, muscle pain. The cause of the syndrome is often speculated to be a neurotransmitter/hormone imbalance, probably involving low serotonin levels, combined with a physical or mental stressor. Serotonin is thought to be involved in sleep, mood and pain perception. A shortage of deep "stage 4" sleep robs the muscles of growth hormone needed for repair and good functioning, makes you tired all the time, and causes "brain fog".
"Learning to live with Fibromyalgia", according to this story, involves low-dose antidepressants to increase the supply of serotonin, supposedly bringing both pain relief and sleep; aerobic exercise - again, to increase serotonin; mild analgesics like Panadol; and avoiding stress, perhaps with yoga or relaxation. Many FMS sufferers have found that they get little benefit from this standard regime. In particular many (though not all) find that even if they can exercise, it makes them feel worse.
Theories about what may cause the same muscle pain, fatigue and cognitive dysfunction in CFS range much wider. They include immune system dysfunction, chronic infection of one kind or another, reactivation of old viruses, disorders of blood circulation, and defects in the way energy is produced within cells. There are a number of experimental treatments aimed at treating these. The main principle in treating CFS is to try and find out what is exacerbating an individual patient’s symptoms, and treat it accordingly. FMS tends to be treated more in a "cookbook" fashion.
An example of the different approaches is in the treatment of irritable bowel syndrome. In FMS this is generally seen as caused by misfunctioning of smooth muscle. The patient is advised to drink lots of water, eat fibre rich foods, and avoid caffeine and alcohol [22]. In CFS bowel problems are more likely to be interpreted as indicating the presence of abnormal gut bacteria (dysbiosis) than a muscle problem. Dysbiosis can lead to over-permeability of the stomach lining ("Leaky Gut syndrome"), which may in turn cause hidden food sensitivities - a possible cause of many symptoms. Some patients experience a turn for the better if their food sensitivities are identified and they are given acidophilus to restore gut flora, and other supplements to improve gut function.
Research at Newcastle and Adelaide Universities suggests that the metabolism of a person with CFS is behaving all the time as a healthy person’s would in response to fever or very strenuous exercise. As well as taking amino acid and other supplements, patients are also advised to take lots of rest. Indeed the Adelaide researchers are adamant that aerobic exercise can do no good and could be positively harmful [23]. In this they are in agreement with the pioneer CFS doctor and researcher Dr Paul Cheney, who cautions patients to avoid aerobic exercise, as that the system producing energy within cells is malfunctioning and vulnerable to further damage [24].
In the previous few paragraphs I have given a very brief and vastly over-simplified description of the main theories about both syndromes. I have by no means covered all the theories and research about either; but I have, I hope, illustrated that, however similar the actual sydromes, the name is important. If you are diagnosed with FMS, then in my opinion, you may be missing out on treatment that might help you. You should certainly not overlook any suggested tests or new treatments you find out about, just because they are said to be "for CFS". (But use your judgement - not all treatments are reputable.)
[ Contents ]
Ultimately, whether we have one disease or many, I believe we have to stand together anyway. Whether labelled FMS or CFS we are equally likely, unfortunately, to be labelled as "pyschosomatic", "depressed", or "hypochondriac". The credibility of both FMS and CFS as physical diseases is under attack [25] and [26], and not enough money is spent on research. It is far too difficult to get sickness and disability benefits, let alone either PBS/Medicare or private health fund rebates for the pathology tests and treatments we want.
Dr Malone gave one good reason for sticking together, when he said that "If you look at it in the political sense, it may not be advantageous to separate the two entities in terms of funding, foundations, etc." [27] It makes even less sense when the boundary between the illnesses is so unclear, and research appears to be on the verge of defining new groupings based on physical evidence of biochemical abnormalities. One day soon the very terms "chronic fatigue syndrome" and "fibromyalgia" will become outdated, and we shall have new terms based on etiology rather than symptoms. Until then, as minority groups with common symptoms (not forgetting those with Multiple Chemical Sensitivities) and a common enemy, it makes no sense to limit our ability to lobby effectively by being exclusive. There is strength in numbers.
[ Contents ]
After writing this article, I read an article by Dr Garth Nicolson about his discovery of mycoplasma infections in people with Gulf War Syndrome, CFS and FMS. He comments:
Since the signs and symptoms of CFS and FMS patients completely overlapped, these patients were therefore considered together(CFS/FMS)[28]
In a paper published in the Scandinavian Journal of Rheumatology in early 2000, a group of Canadian researchers report that in their group of 74 people diagnosed with FMS, 58% of the women and 80% of the men also met the 1988 Centre for Disease Control (CDC) criteria for CFS. Like Dedra Buchwald in 1996 [14], they found that "Compared to those with FMS alone, those meeting the case definitions for both FMS and CFS reported a worse course, worse overall health, more dissatisfaction with health, more non-CFS symptoms, and greater disease impact." They concluded "There is significant clinical overlap between CFS and FMS." [29]
For a discussion of problems with the current official Centers for Disease Control (Fukuda et al) definition which was published after I wrote this article, see U.S. Case Definition of Chronic Fatigue Syndrome: Diagnostic and Theoretical Issues by Leonard A. Jason et al from the Journal of Chronic Fatigue Syndrome Vol. 5, No. 3/4, 1999, pp. 3-33.
The About.com CFS/FM site has a long list of links to articles about the connection between CFS and FMS.
A paper published in the Journal of Chronic Fatigue Syndrome, Vol. 11(4) 2003, pp. 3-18 by a group of researchers including Neil McGregor, PhD (Newcastle) and Kenny De Meirleir, MD, PhD (Brussels) included the following comments:
Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFS) are related yet overlapping disorders both characterised by sleep impairments, fatigue, headache, muscle and joint aches, swollen and painful lymph nodes, nausea, gastro-intestinal symptoms and neurocognitive disturbances. The severity of the patients' symptomatology appears to be the only differentiating feature, however none of the currently internationally accepted criteria (1-3) stipulate the usage of a severity index. A number of 'chronic fatigued' patients fulfill both the CDC (Centers for Disease Control and Prevention) case definition for CFS and the ACR (American College of Rheumatology) criteria for FM (4-6). Indeed, when comparing these criteria (Table 1), one can only conclude that differentiating these syndromes is nearly impossible. [my emphasis]Laylander (1999) suggested to combine FM and CFS into 'chronic pain-fatigue syndromes' (7,8). Remarkably, FM is categorised as a rheumatic disorder, while CFS patients are generally referred to practitioners of internal or neurological medicine.
[ Contents ]
Now read on ... for some differences between CFS and FMS.
1. USA Government Center for Disease Control, Atlanta - CFS Home Page
2. Michael J. Goldberg M.D., F.A.A.P., Chronic Fatigue Syndrome in Children and Adults and its Connection to ADD/ADHD.
3. Hillary Johnson, Osler’s Web: Inside the Labyrinth of the Chronic Fatigue Syndrome Epidemic. Crown Publishers, New York, 1996; page 53.
4. Hillary Johnson, Osler’s Web, page 54.
5. RH Dunstan, NR McGregor, HL Butt, TK Roberts, M Zerbes, and IJ Klineberg, Homeostatic Heterogeneity In CFS Patients, presented at the Sydney 98 CFS Conference
6. The American College of Rheumatology 1990 criteria for the classification of Fibromyalgia
7. Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual, by Devin J. Starlanyl M.D. and Mary Ellen Copeland M.A. M.S.; New Harbinger Publications Oakland CA, 1996: Chapter 3 and throughout.
8. "Limitations of the ACR Diagnostic Criteria," in the Fibromyalgia Association of Washington's FMS Monograph, 1999.
9. At the time of writing, a list called "The most common symptoms of fibromyalgia" by Bruce Massau, M.D., was available on a website called Chronic Pain Solutions.
10. "Dr. Jay Goldstein's CFIDS Symptom Checklist"
11. Leon Chaitow MD: "Fibromyalgia: The Muscle Pain Epidemic - Is it ME by Another Name?" - from HealthWorld Online.
12. Wallace, Daniel J and Wallace, Janice B; Making Sense of Fibromyalgia; Oxford University Press 1999; p. 75.
13. ".. studies by Dedra Buchwald, M.D., of the University of Washington, Anthony Komaroff, M.D., of Brigham and Women’s Hospital and Don Goldenberg, M.D., of Newton-Wellesley Hospital ... have shown that CFS and FMS overlap in patients by as much as 75%." From "Overlapping Syndromes" on the website of the FM Network.
14. Quote from study by Dedra Buchwald, M.D, Rheumatic Disease Clinics of North America 22(2):219-243, 1996 in "Fibromyalgia Basics", on the website of the FM Network.
15. Muhammad B. Yunus, M.D.,"Dysregulation Spectrum Syndrome: A Unified Concept for Many Common Maladies", in Fibromyalgia Frontiers Fall 1996, Vol.4, No.4. (the journal of the National Fibromyalgia Partnership, Inc.)
16.. Mark J. Pellegrino MD, The Fibromyalgia Survivor; Anadem Publishing, Columbus Ohio, 1995.
17. Talk by Dr. Daniel Malone as reported in "Lifeline," the quarterly newsletter of the Wisconsin CFS Assoc. Vol. 11, No.2, pages 5-8.
18. Erich D. Ryll, M.D., Asst Clinical Prof. of Medicine, Division of Infectious & Immunology Diseases, Univ. of California - patient handout on Marilyn K's site.
19. Dr E.M. Goudsmit: "Basic Introduction to CFS(ME)" (medical professional version), at Axford’s Abode.
20. McGregor NR, Dunstan RH, Butt HL, Roberts TK, Klineberg IJ: Host verses Acquired Responses in Chronic Fatigue Disorders, presented at the Sydney 98 CFS Conference.
21. See, for example, Teresa Krukenberg’s book When the Pain is Real!! Fibromyalgia: The Chronic Muscle Pain Syndrome; May Publishing, Melbourne Australia; 1996. [book extract]
22. See, for example, Fibromyalgia: what you can do about chronic pain and fatigue, by Miryam Ehrlich Williamson; Allen & Unwin, 1998; p. 74. [book extract]
23. Anelie Walsh, Summary of Sydney Conference 99 Patient’s Day, also Aerobic Exercise isn't the Cure on this website.
24. David Hoh, "Treatment at the Cheney Clinic", CFIDS Chronicle July-August 1998 (reprinted in the Queensland ME Quarterly, February 1999).
25. See the Royal Australasian College of Physicians' Draft Clinical Practice Guidelines on the evaluation of prolonged fatigue and diagnosis and management of CFS, and
26. Geoffrey O Littlejohn, "Fibromyalgia syndrome and disability: the neurogenic model" (MJA 1998; 168: 398-401).
27. Talk by Dr. Daniel Malone, "Lifeline," Vol. 11, No.2, pages 5-8.
28."Mycoplasmal Infections in Chronic Illnesses: Fibromyalgia and Chronic Fatigue Syndromes, Gulf War Illness, HIV-AIDS and Rheumatoid Arthritis" by Dr Garth Nicolson et al, from the Medical Sentinel of Sept/Oct 99.
29. "Co-existence of chronic fatigue syndome with fibromyalgia syndrome in the general population. A controlled study." by White KP, Speechley M, Harth M, Ostbye T, in Scand J Rheumatol 2000;29(1):44-51 (Abstract)
[ Contents ]
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