Copyright 2002, E. Franklin Livingstone, M.D.

Millions of Americans struggle with chronic muscular aches and pains, often receiving insufficient help from a busy medical professionals. Sometimes, other medical, physical or emotional problems are more pressing or more easily diagnosed and treated. Pain remains somewhat enigmatic and difficult to diagnose since it can be a symptom of so many ailments: physical or emotional. In a busy office practice, these complaints, unless incapacitating, can be ignored or postponed until "the next visit." In addition, it seems as though there is a lot of misdiagnosis and inappropriate, ineffective treatment. Frequent and long term chiropractic manipulation, and simple heat and massage may feel good, but neither are very likely to aid significantly in the resolution of these muscular problems, in spite of the fact that they are used extensively.

Fibromyalgia, as well as other muscular pain syndromes, is a curable disease of the muscles. While it is not life threatening, it can be a  miserable and frustrating problem that can go on indefinitely. It is a cyclical deteriorative condition of muscles that causes stiffness, discomfort and poor tolerance to activities. There are many factors that can cause the problem, and there are just as many that can work against you and your muscles to keep it going. You will learn about all of this as you progress from topic to topic. You will learn that anything that causes prolonged muscle tension and/or decreased blood flow to the muscles will tend to cause deterioration, and that whatever you can do to decrease muscle tension and increase blood flow will aid in healing. You will learn about "cyclogens" those factors that tend to add to, or perpetuate muscle deterioration, and how to recognize and systematically eliminate them. You will be able to develop a comprehensive program geared specifically to your situation, and if you follow through accurately and persistently, you will cure yourself.
Muscular pain syndromes are complicated, but simple problems. They are complicated by the many factors which can cause the deteriorative cycle to continue. They are relatively simple problems, on the other hand because they are easily understood as a cycle of muscle tissue deterioration. You will, once and for all, gain an understanding of just what has been plaguing you for so long. In this new knowledge, there is strength and power. You will be able to develop a positive attitude, a determination to be successful in controlling what has been controlling you, telling you how you felt and what you could do. We can show you all of this, but like the horse being led to the water, we cannot make you drink deeply of "the water," (the knowledge that you need to be successful). You will have to decide for yourself if it is important enough for you to study, to learn, and to follow through. For the more you learn, the better you position yourself to be successful in your rehabilitation program. Always say you'll try, never that you can't or that you quit.

Before starting your rehabilitation program, you must consult your physician. No one can prescribe a rehabilitation program through a book or on the internet. Every person is a little bit different than any other person and the individual problems each person has differ, as well. It is very important that you know exactly what might be causing your problems, whether they be pain, stiffness, weakness, changes in sensation (what you feel), difficulty with movement, or whatever they may be. Discuss with your physician the rehabilitation program that you are going to follow and listen to his/her advise. Make a partnership with your doctor. He or she will welcome your positive, independent attitude, and can be very helpful to you in the design of your rehabilitation program. Discuss therapies such as medications, cold packs, heat, exercises, stretching, walking and other stress reduction techniques before starting. Your doctor may have some additional ideas that could prove very helpful for you, or perhaps warnings as a result of abnormalities found on your physical examination or medical history. Do approach your own rehabilitation program with a positive and determined attitude, but always use your brain power and others' brain power first. It is far better to be safe than sorry.

Before starting any new therapy, no matter how simple or safe it appears, always consult your physician. Your physician will want you to be successful. Your physician will want to help you be safely successful. Your physician will be your friendly advisor if you allow.


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  Fibromyalgia for Dummies 

The Fibromyalgia Advocate


"An hour of pain is as long as a day of pleasure." English Proverb.

"Although the world is full of suffering, it is full also of the overcoming of it."

Helen Keller, Optimism.

Fibromyalgia is a Latin derived term that stands for pain that comes from muscles. More specifically, from muscles and the connective tissue associated with muscle (Fibro-my-algia: Fibro = connective or fibrous tissue, my o = muscle, algia = pain). Connective tissue is the "glue" that holds our individual cells and tissue together. Let me give you an example; Have you ever eaten steak that was very hard to chew? Have you ever eaten steak that was very easy to chew? The major difference in the two was in the amount of connective tissue. Muscles have lots of components, muscle cells and connective tissue. So Fibromyalgia describes discomfort that comes from these two components of muscle.

This is a not uncommon problem and may affect many of us at times to some degree. In this chapter we will discuss what Fibromyalgia is, how it starts, and why it can continue indefinitely if not understood and controlled with a comprehensive rehabilitation program.

Fibromyalgia has been known by several other terms in the past. Fibrositis has been the most frequently used, but is inaccurate, implying that this is primarily an inflamation. This is not so, even though inflammation plays a role. Today, Fibromyalgia and myofascial pain syndrome (myo = muscle; fascial = connective tissue) share in the description of this malady. We will use the term Fibromyalgia in this book, though there are differences between the two.

There are many signs and symptoms that are common in Fibromyalgia. Everyone with this problem has muscular pain, tenderness and periodic stiffness. The level of the discomfort varies and tends to wax and wane (increases and decreases). There are good days and bad days. In some cases they all seem to be bad. There are usually tender points found on physical examination. These areas are very pressure sensitive causing localized pain, and sometimes pressure on these areas causes pain to be felt in some other area. The latter are called "trigger points," and the phenomenon of feeling discomfort at a site different from where the pressure is applied is called "referred pain."

These muscular problems are usually aggravated by activity, but interestingly enough, they are aggravated by both over activity and underactivity, an important concept in treatment. If you over do it you get sore and stiff, and if you under do it you get stiff and sore. You must always strive to maintain your exercise and activity levels between upper and lower limits of tolerance (moderation). These muscular problems, instead of healing up, often progress gradually. Certain people have a tendency toward this problem and once it gets started, it seems to continue and worsen. If you are one of the people who has been struggling with this for some time, then you are likely one who has a tendency for this problem, just as some people have tendencies toward other bodily problems and diseases. But take heart, there is hope as you will see.

There are common patterns of muscular involvement such as the back of the neck, around the shoulder blades, the lower back and buttocks, but any muscle or group of muscles can be involved. The pattern in any given case may be related to the reason for the development of this problem in the first place. Often the reason for starting is a muscular strain injury or overuse of muscles not accustomed to the activity they are forced to do. In some cases, the problem seems to gradually arise for no apparent reason.

There are often associated symptoms that usually relate to autonomic nervous system activity. The autonomic nerves are part of your nervous system and are involved in the control of visceral function for the most part, that is, functions of your organs, of your heart, blood vessels, etc. We often see autonomic nervous activity such as sweating, blood circulation changes or skin coloration changes over the involved muscles. Lacrimation (tearing) and salivation (saliva production in the mouth) occur sometimes, and infrequently seen are dizziness and ringing in the ears when muscles of the head and neck are involved.

With upper back and neck involvement, headaches are a frequent problem. These usually radiate from the neck to the back of the head and sometimes to the sides or front of the head. These headaches are usually dull and aching and represent muscle tension headaches. They may occur daily and even awaken your from your sleep.

Associated depression is not uncommon, especially with the frustrating, long term problems that Fibromyalgia can cause. Anxiety can also be present and a result of Fibromyalgia, or it can predate the muscle problem and may actually be one of the reasons it developed in the first place. Sleep disturbances are always present in severe Fibromyalgia and can be caused by the problem or can be a cause of the problem; a "cyclogen." In any case, where Fibromyalgia is present, sleep problems will help to keep it from resolving. "Nervous stomach" and irritable bowel problems are often associated with Fibromyalgia, however, they were usually present before the fibromyalgia and may point to some similar nervous system process or processes. The digestive tract and muscles represent body surface organs (the digestive tract is open at the mouth and anus, and though we think of our stomach and intestines as being internal organs, they can also be considered body surface organs). Perhaps the nervous hyperactivity in Fibromyalgia involved muscles and that found in stomach and bowel conditions, resulting in tissue damage, have some similarities and may, in fact, be related at the level of brain and nervous system function. This might explain why so many people have combinations of these problems and why emotional and psychological stress can help to perpetuate the problems and magnify the discomfort and impairment.

Most everyone with fibromyalgia can recognize that certain situations, activities or environmental changes cause increases in the level of discomfort. Oncoming cold weather will often cause increases in symptoms. Prolonged, repetitive or vigorous activities, or prolonged positioning will aggravate this condition. A sedentary lifestyle and poor physical fitness probably cause predisposition for Fibromyalgia and can help to keep it from healing and resolving.

General fatigue is a frequent complaint with Fibromyalgia. There are several components to this. The sleep disturbance plays a key role and usually what sleep is attained does not cause refreshment. The daily frustration of trying to cope with this is another factor, and Fibromyalgia is an emotional strain, to put it mildly. The muscles involved are also more easily fatigued because of changes that occur to them, changing their ability to function.

The sleep disturbance that is so common in Fibromyalgia is a lack of deep non-R.E.M. sleep.

Certain factors or activities cause symptom reduction or relief. Warm, dry weather generally makes people feel a bit better. A hot shower or bath can be very relaxing, reducing discomfort at the time and for sometime afterward. Moderate activity and short bouts of rest and relaxation help to reduce discomfort and stiffness, but rest and inactivity can be a two-edged sword. Massage can make you feel better, but depending upon how the massage is done, might be aggravating. Gentle massage is temporarily soothing and generally tolerated well, but deeper more vigorous massage should be done only by trained therapist.

The local application of heat is a standard in many treatment protocols. Heat can be helpful. The use of moist heating pads, hot water bottles, and electric heating pads (at low heat settings) are soothing and decrease discomfort temporarily. In general, heat may have a very limited ability to help resolve these problems, however, while the heat is in place, the pain is "masked." Heat should be used with some reservations as using heat may be both beneficial and harmful. The involved muscles are in a deteriorative (not completely healthy) state in Fibromyalgia. There may be some swelling (edema) in these muscles, and the application of heat may tend to cause an increase in the swelling. Therefore, the use of heat should be monitored closely. If you are more uncomfortable 15 to 30 minutes after the heat is removed than you were prior to the application of the heat, then it is probably not the right treatment for you at this time. Heat may be more appropriate later, after the muscles are healthier.

The muscular involvement in Fibromyalgia shows certain patterns. We will now focus our attention on the individual muscle cells at the microscopic level. Muscles, like all the different types of tissues in our bodies, are made up of individual cells. Grouping of similar cell types make up tissues; skin is tissue made up of groups of individual skin cells and connective tissue (the glue that holds them together) just as muscle tissue is made up of muscle cells and connective tissue. In muscle, the individual cells have a transparent envelope of connective tissue around them. The muscle cell and connective tissue organization is complex, there is a lot of connective tissue and the cells and connective tissue must work together if the muscle is to function properly. If the relationship between the cells and connective tissue is altered by disease abnormalities, muscle efficiency will decrease with apparent loss of strength, poor endurance and easy fatiguability. In fibromyalgia, there are alterations in the interactions of muscle and connective tissue. The muscle cells are the active contractile parts of the muscle, the connective tissue does not contract, but it must allow the muscle cells to function. In Fibromyalgia, the connective tissue becomes more restrictive and impairs muscle function.

Fibromyalgia is a cyclical process, and it is a complex intermingling of your mind and body functions as your will learn. Fibromyalgia is a soft tissue process, that is, it involves muscles (soft tissue, not bones). There can be underlying bone or joint problems, such as arthritis, that can affect Fibromyalgia. Fibromyalgia can exist and continue without any other underlying bodily problems. It is important that your doctor examine you and tell you if there is involvement of bones, intervertebral discs, joints, or ligaments (any structure other than muscles), since treatment of these problems will require other methods than those described here.

Muscle tissue can be irritated or damaged by many factors; it might be physical trauma, such as injury or overuse, insufficient blood flow to keep the muscle tissue healthy, or prolonged tension resulting from poor posture, or other causes.

Immobilization or inactivity may cause muscle deterioration, and can be a perpetuating factor in already involved muscles. Infrequently, infection is the cause of muscle tissue damage, and this problem can develop after viral illness, for example. Emotional tension or psychological distress issues can also cause irritation and damage to muscles just as they can cause irritation and damage to the stomach or intestines in gastrointestinal related problems. The result of muscle tissue irritation is damage or deterioration of that muscle and progression of the muscular involvement.

The discomfort tends to cause more muscular tension in the areas involved, which further aggravates the problems. This relates to the fact that your mind and body combine to cause splinting of painful areas, that is, tensing of muscles to reduce movement, supposedly to protect the area from further damage. Unfortunately, this adds more muscle tension over prolonged periods, increasing muscular work and decreasing blood flow. In already damaged and poorly tolerant muscles, this further aggravates the problems. The reduction of blood flow due to muscular tension may be relatively small, but over time it becomes very important, causing impaired healing and in progression of muscle tissue damage or deterioration.

Normal muscle function is the contraction - relaxation sequence, and our muscles tolerate this well and for long periods if they are healthy. The act of muscle contraction causes "old" blood to be forced out of the muscle and relaxation helps to allow new, fresh blood to enter the muscle. Prolonged tension is not well tolerated partly because of the loss of this blood pumping function of normal muscle activity. Soon the reduced blood flow results in the build up of waste products in the muscle cells and tissue. At the same time, the delivery of oxygen and nutrients to the muscle is reduced. This is very significant because the healing process ceases to be effective and there is progressive damage to muscle cells.

As a result of tissue damage, inflammation occurs with both positive and negative results. The inflammatory response is part of the body's attempt at healing the damage and restoring health to the muscle tissue. It also causes swelling and pain, and the pain can then help to cause more tension in the muscle. Can you begin to see how the many factors involved feedback on one another to make this a cyclical process?
Inflammation can also cause microscopic scar tissue formation (fibrosis), which can be restrictive of muscle cell function. We have discussed earlier the necessary interaction of muscle cells and connective tissue. The inflammation process may cause other alterations affecting the interaction of muscle and connective tissue. These factors will limit muscle contraction and can cause shortening of muscle, restrict movement and produce additional discomfort.

Let's focus on the cycle of muscular deterioration and then we will discuss the "cyclogens;" those factors which can initiate or perpetuate the cycle so that healing and resolution do not occur. Muscular tension and autonomic nervous activity both cause decreased blood flow. With prolonged reduction in blood flow, there is tissue deterioration and impaired healing. Healing requires lots of blood flow. The autonomic nerves control blood flow by controlling the diameter of blood vessels. When the nerves make the blood vessels get smaller in diameter, there is reduced blood flow. In any case, whatever causes decreased blood flow will tend to facilitate deterioration by decreasing nutrition, waste removal and healing in affected muscles.
Muscle tissue has a high metabolic rate and needs sufficient blood flow to remain healthy. Healing processes also require abundant blood flow. When the blood flow is shut off or reduced to a particular area, damage occurs rapidly. Eventually, if reduced enough, that area of tissue dies. That is what happens in heart attack. Part of the heart muscle doesn't get enough blood for an intolerable length of time and tissue damage and actual death of cells occurs. With reduced blood circulation, there is rapid build up of waste products and insufficient delivery of oxygen and nutrients which cause more problems for already damaged muscle tissue and can be a cause of more pain.

Muscular irritation and injury can be caused by muscle strain and overuse of muscles. As I have mentioned, it can be aggravated by prolonged muscular tension caused by poor posture, prolonged positioning, or with emotional or psychological problems. With increased muscular irritation (damage), we see more inflammation, spasm and muscular tension causing increased muscle work and decreased blood flow. Is the cycle making sense to you? These are important concepts in the perpetuation of Fibromyalgia.

As you can see, once the process has begun for any reason or reasons, it does not take much to perpetuate the cycle. You can liken this cycle and its perpetuation to the rolling of an automobile tire. Most of us at one time or another have had to handle a bulky, heavy tire when we've had a "flat." The tire is difficult to carry, but if you stood it up and started it rolling, it took very little effort to keep it up and rolling, a little push every few feet and it rolled nicely. That is similar to the cycle in Fibromyalgia and muscular pain syndromes in that once it is started, it takes very little to keep it going.

It is important to understand why the cycling occurs and how you can prevent it. The "cyclogens" are critical and you will have to become an expert at identifying what factors in your life (in your behaviors, in activities, and in your emotional and psychological status), tend to perpetuate this problem. You've got to become objective about this. Stop thinking about it in terms of how much you hurt and what you can't do. Start thinking about it in terms of why it is affecting you and what are you doing to perpetuate or aggravate it. Everyone who has this problem knows well what their Fibromyalgia does to them, but what they are ignoring, is what they do to their Fibromyalgia. This is the most important aspect of the process.

If you won't practice thinking about and identifying the factors aggravating your problem, you are unlikely to gain control, and it may be with you for a very long time. If you try, you'll be able to identify reasons for both increases and decreases in your symptoms. Don't expect to become expert at this overnight. If you are like most with this problem, you've spent a lot of time and practice at being aware of what Fibromyalgia does to you. Being aware of what you do to perpetuate the fibromyalgia is more difficult and ever so much more important. In fact, this last point is critical to resolution of the fibromyalgia process. You must change your way of thinking about this problem.
There are four major categories of "cyclogens." The most common are periodic reinjury or strain of involved muscles, overuse of involved muscles, sleep disturbances, and emotional and psychological factors. All of these categories can be subdivided into may individual factors. The specific factors involved in any given case will be individualized to that persons' activities, behaviors, and emotional and psychological status. Take a closer look at yourself and your situation. It may be difficult to be objective at first, but don't give up, practice will allow you to improve at this.

The four categories of "cyclogens" are common in most people with Fibromyalgia, to some extent. Most, however, don't want to admit that emotional and psychological issues are important. It seems that in our society there is a stigma attached to these mental factors. It is not "macho" to have symptoms related to stress. In some cases, however, the most important perpetuators of Fibromyalgia relate to stress, tension, anxiety, frustration, anger, depression and the list goes on.

Fibromyalgia may tend to aggravate these problems once it is present, so even though these tendencies were not recognized before the Fibromyalgia, they may be potent "cyclogens" for perpetuation. It is important for you to begin to realize the complexities of this syndrome and to understand the interactions of mind and body, if you are to learn enough about this problem to gain control and gradually resolve it.
Let's turn our attention to the factor of muscle tension. We have already talked about this to a limited extent.

Psychological and emotional problems such as tension, depression, frustration, anxiety, anger and others can cause tension. If you are one with "nervous stomach" tendencies, then your may recognize your tension as an upset or "tight" stomach. It is important that you become aware of how nervous tension effects muscular problems. Muscular tension can result causing impaired blood flow, impaired healing and facilitation of muscle tissue deterioration. Muscular tension can also be caused by "splinting" or "guarding" patterns in muscles as the mind and body's reaction to discomfort. Your mind and body produce this muscular tension consciously and subconsciously in order to protect the areas from movement and to reduce discomfort. You must be able to identify causes of stress and tension and to deal effectively with them, so that they do not continue to be factors perpetuating muscular deterioration.

Poor movement patterns can develop with chronic guarding behaviors; a limp is a good example. These dysfunctional motor patterns are abnormal and produce abnormal muscle use and tension; patterns that can be important factors in your ongoing problems. You must learn to recognize these abnormalities as what they are, maladaptive behaviors, and start correcting them. It all takes effort, and no one can do it but you.

Postural issues are commonly a significant problem area and are potent "cyclogens." Low back, upper back and neck problems are particularly susceptible to the added stress of poor posture. First you must become aware of our posture abnormalities and realize their importance. Then you can start to do what it takes to correct these problems. Refer to the topic on posture for a more detailed discussion of these matters.

One interesting aspect of Fibromyalgia is the definition of acute vs chronic. This has implications in treatment. Calling something acute indicates that it occurred or started recently, while chronic means that it has been present for a while, let's say about six months or more. From this understanding, most with Fibromyalgia have a chronic illness, but from the discussion in this chapter, I hope you are getting a feel for the fact that this problem is an acute process that can go on for prolonged periods because of many daily aggravating factors. If you are not careful, for example, you may have many minor aggravations over the course of a day. Any one of these aggravations may be relatively unimportant, but their effects are cumulative, that is, they add to each other, resulting in significant aggravation by the end of the day.

Any treatment program that is considered must take into account all aspects of the cycle of this process if it is going to have optimum success. All "cyclogens" must be identified and systematically dealt with. Any "cyclogens" left unattended will be there to perpetuate the process, even with partial treatment, and may cause the treatment program to be unsuccessful.

The most important tool that you will have at your disposal in your attempts to control and resolve Fibromyalgia is what you know. The intent here is to put the information you need into a format that you can learn so you can develop a planned, comprehensive rehabilitation approach. In the long run only you can prevent cycling of Fibromyalgia, and only you can control and resolve this non-life threatening, but miserable problem.


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I. EDUCATION: You must learn as much as you can about all of the many aspects of your problems. This information is an excellent starting point, but don't feel confined, explore, use your libraries and bookstores. The investment of time and effort that you make in your education will pay dividends. Without adequate knowledge, your likelihood of success is not high

II. PREVENT THE CYCLE OF DETERIORATION: Your muscles will not heal completely unless you do this. You must learn what it is about you, your behavior, your activities, and your emotional and psychological status that gives you the tendency for this problem. Your muscles would have healed themselves long ago if it were not for the "cyclogens." If you make a mistake and aggravate yourself, treat the aggravation and learn from the mistake so that you never make it again. Mind yourself in all activities, put your brain in gear, before putting your body in motion. Identify and eliminate all "cyclogens." Become more aware of tension in your muscles and of factors or situations that tend to cause tension. If inner psychological or emotional difficulties are feeding into your problem, deal with them. Do some soul searching and introspection to get a handle on these issues, and seek professional help if necessary, knowing that nobody but you can really change your attitudes and beliefs. You cannot ignore any "cyclogens" and expect to resolve muscular problems as they will prevent complete healing.

III: FACILITATE HEALING: There are four aspects to pursue and all of these cause decreased muscle tension and increased blood flow.

A. COLD THERAPY: Use your cold packs frequently and on a time schedule. Use your cold packs when needed for exacerbations, such as with overdoing it. Use your cold packs for no less than 25 to 30 minutes when you do use them.

B. STRETCHING PROGRAM: Develop a regular stretching program and perform it frequently, but for short duration. Do stretching before and after exercise, immediately after getting up from sitting or lying, immediately after using your cold packs, and about every ten minutes during the day. You will have to work at developing good habits, bad habits seem easy enough to develop.

C. EXERCISE PROGRAM: Your exercise program, in the long run, may be the most important aspect of your program. Until muscle healing occurs, however, you must approach it with caution so that it does not aggravate your condition. You have upper and lower limits of tolerance, and stretching these limits will work against you, causing the cycle of muscular deterioration to continue. At first, start your exercise sessions of three to ten minutes about every 30 to 40 minutes or so. Gradually progress the duration and intensity of your sessions, and as you do, you may gradually decrease the frequency. Remember, more frequent, low intensity exercise is better tolerated and better for you than trying to push too fast.

D. ACTIVITY PROGRAM: Any activity you do, physical or mental, that is not injurious to you in any way and that does not aggravate your muscular condition, probably has at least some therapeutic value. Keeping your mind and body focused on activity has important effects on control of discomfort and on your general well being. You must not allow daily activities to cause recurrent aggravation. Daily structure is very beneficial. If you are not currently working at a regular, full-time job, you should start structuring your day around your rehabilitation program and your activities. Volunteer at a local hospital or senior citizen center Get out of the house on a regular basis, don't let the television control the structure of your day. Find new hobbies, things you can enjoy and find self-satisfaction in. Don't just let the world go by, or it will, leaving you behind.

E. MEDICATIONS: Take an anti-inflammatory medication or acetaminophen on a times schedule.

F. TREAT EXACERBATIONS IMMEDIATELY AND EFFECTIVELY: If you make a mistake and have an aggravation, even if you don't think it was your fault,
Start treatment immediately, then think about it. Use cold pack therapy, short Rest/relaxation, and a gradual return to stretching, exercise and activity. Learn from your mistakes, but don't delay treatment.

IV. OTHER: You must accept the fact that you have chronic pain and do the best you can with it. Start setting goals for yourself, in terms of your rehabilitation program, work, recreation, social activities and hobby or avocational interests. If your pain is getting to you, get angry at it to blow off your frustration and get back to your program. Your ultimate goal should be to get into the best physical condition that is possible and stay that way. Optimize our relaxation response by practicing relaxing several times each and every day. Instruct your family and close friends to reinforce only well behavior. They should pat you on the back for acting normal, not fuss over you because you are having discomfort or acting sick and disabled. Make a partnership with your doctor, use but don't abuse him or her. Be motivated and determined to persist in your own rehabilitation. If you quit, no matter where along the path, then you lose. The biggest difference between the successes and the failures in this world is persistence and positive attitude.

If you follow the guidelines in this book you will be helping yourself. It is a great feeling to help yourself, a sense of accomplishment. It increases self-esteem and self-worth. There isn't anything in this book that you cannot understand and do if you will persistently try. Now, go do it for yourself. You will be grateful to yourself for the rest of your more enjoyable life if you do.


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Copyright 2002, E. Franklin Livingstone, M.D.

Permission is granted to use this information for personal use. An other use requires expressed written permission from the Author.