Fibromyalgia

Fibromyalgia

What is fibromyalgia?

Pain. Is it all in your head? It used to be that this condition was “labelled” this way. Now, fibromyalgia (fi-bro-my-al-gia) is classified as a chronic disorder of the musculoskeletal system (muscles and bones). Fibromyalgia is characterised by widespread pain and stiffness in the body, which is amplified in the way that the brain processes signals alerting pain sensations.

Pain is described as ‘areas of tenderness’ in the body’s muscles and bone structures. A sufferer will also complain of constant fatigue. These types of symptoms make for difficult diagnosis, as the majority are considered medically subjective. Testing is challenging as there are no measurable findings medical professionals can use to make a definitive diagnosis. Pain thresholds are also different for different people. A clear cause is also challenging to determine, and as such has led to disagreements between medical professionals as to whether or not the disorder is even legitimate.

Fibromyalgia, however, is now more widely accepted as a condition the world over than it was initially, as more and more people raise similar symptom complaints.

Pain is often accompanied by mood problems, sleep disturbances and memory issues which can sometimes be triggered by a physical trauma or following surgery, psychological stress or even an infection. It’s also been noted that symptoms can develop gradually over a period of time and not seemingly be triggered by a specific event or condition at all.

The condition itself doesn’t appear to cause any damage to the body’s joints or organs, but constant stiffness and pain can wear down a person and leave them feeling incredibly fatigued. This in turn can have a debilitating impact on a person’s quality of life.

Research has noted that women (particularly those in middle-age) are more likely to be diagnosed with this condition than men. Other high-risk factors appear to be accompanied by those who have autoimmune conditions, such as rheumatoid arthritis. Many who are diagnosed with fibromyalgia are also treated for conditions such as anxiety or depression, irritable bowel syndrome, tension headaches or temporomandibular joint disorders (TMJ).

A chronic condition, fibromyalgia is an illness that requires constant symptom management along with a variety of lifestyle changes to help alleviate discomforts. Research is still being done to better understand the disorder and what actually causes it. The legitimacy of undetectable pain is no longer being assumed as an excuse some use to try and get prescribed pain medication from medical professionals. In some instances, lifestyle changes are proving more effective than medication in alleviating symptoms.

What causes fibromyalgia?

Research into the cause of this disorder has spanned decades, and many now believe they are close to understanding how and why this condition occurs. Factors that are believed to contribute to its cause include:

  • Stress: The effects of prolonged stress (from as little as several months to many years) and its relationship to hormonal disturbances in the body is being extensively researched as a possible link to the development of fibromyalgia.
  • Trauma: Trauma of a physical or emotional nature has been noted as a possible trigger or cause link in those who have been diagnosed with fibromyalgia.
  • Infections: It has been noted that prior infections and infectious conditions could possibly trigger or worsen symptoms of fibromyalgia.
  • Genetics: Risk of developing this condition appears to be higher if someone in your family has similar symptoms or has been diagnosed with the condition. Researchers are looking into how genetic mutations may play a role in how this condition occurs, but are still uncertain as to which genes could cause the disorder.

In general, the underlying cause of the disorder is, and always has been, a complex issue, that has many in the medical field scratching their heads over a variety of proposed theories. Some suggest that it must be that the brain somehow lowers a person’s pain threshold at some point, making something that once wasn’t an issue, a painful experience at another time.

Other theories delve into nerves and receptors in the body and argue that these become repetitively more sensitive to stimulation (i.e. pain signals ‘overreact’ and exaggerate sensations of pain in the body). The thinking is that repetitive stimulation somehow alters the brain and results in an abnormal increase in levels of neurotransmitters (chemicals in the brain which signal or alert the body to pain). The receptors, are then thought to ‘memorise’ this pain being signalled and become increasingly sensitive, and thus overact when the sensation arises again.

What are fibromyalgia trigger points?

Trigger points of fibromyalgia (illustration)Doctors have determined 18 different trigger points (broken down into 9 pairs) in the body based on cases of fibromyalgia around the world. Many may describe their symptoms of pain as “I hurt all over”.

In the process of trying to determine what is painful and why a person is feeling sensations of pain, medical doctors have broken down common areas of the body into what is now known as ‘trigger points’ (areas of the body where pain sensations are most prominent).

For someone experiencing this condition, pressing these different trigger points will be incredibly painful. A normal person will likely describe the pressing sensation as pressure and not as pain.

The trigger points which will be assessed during a consultation with a doctor are:

  • Back of the neck: Pain may be felt in the area where the skull meets the neck (at the base of the head). Common influencers which may be triggering or causing the pain could be injury (repetitive injuries to the same area), activities which strain the neck (uncomfortable sleeping positions or slouching) or rheumatoid arthritis.
  • Front of the neck: Pain can also occur at the front of the neck, just above the collarbone and on either side of the larynx.
  • Upper back: Pain is particularly tender in the area where back muscles connect to the shoulder blades (connecting tendons and muscles) in the body.
  • Lower back: Pain is commonly felt at the top of the buttock area, at the base of the back (lower back).
  • Shoulders: Some experience pain in the area of the upper back that is halfway between the edge of the shoulders and the base of the neck.
  • Chest: Pain may also be felt on either side of the sternum (or breastbone), just beneath the collarbone in the chest area (close to or near the second rib).
  • Hips: Where the buttock muscles curve and join the thighs of the body, pain can occur. Some triggers may be similar to those of osteoarthritis (although pain with this condition is more typically felt in the joints).
  • Elbows: Pain and stiffness can also be felt in the forearms, near (or below) the crease of the elbow and out towards the outer side of each arm. Some triggers could be repetitive strain injuries to the same area or tendonitis.
  • Knees: A person with fibromyalgia will experience pain, tenderness or stiffness on the inside of each knee pad.

Is there a link between sleep disturbances and fibromyalgia?

Woman unable to sleep and in discomfort during the night.

Many who have been diagnosed with fibromyalgia have complained about sleep disturbances as well as typical symptoms of the disorder. In that sense, there is a link that appears to be fairly common for those suffering the chronic effects of the disorder.

A person may not necessarily have problems falling asleep, but it has been noted that many are light sleepers and can be easily woken once asleep. One reason this may happen is that a person may be repetitively interrupted by bursts of brain activity (similar to when a person is awake) during sleep. Interruptions have been carefully researched and appear to happen to sufferers, even when in their deepest state of sleep.

Many with fibromyalgia also complain that they awaken feeling unrefreshed and as if they’ve not slept at all. Bursts of brain activity preventing restful sleep is one theory as to why the body is then unable to rest and ultimately feel rejuvenated once awake. As well as from the effects of constant pain, a related symptom, such disturbances to sleep can create a constant state of tiredness or fatigue.

What about depression and fibromyalgia?

Portrait of a young female with mental problems, suffering depression

More than half of those diagnosed with this disorder are also being managed for mood disorders such as depression or anxiety. Many medical professionals have deduced that the reason for this comes down to stress. Constant pain and fatigue can place quite a bit of emotional turmoil on a person’s well-being and ultimately result in a person becoming withdrawn and feeling under persistent stress.

Over prolonged periods of time, this can lead to disorders such as depression, as well as changes that impact a person’s ability to concentrate, and their short-term memory.

How does fibromyalgia affect the body?

Signs and symptoms

Pain trigger points may not always be used as a basis for a fibromyalgia diagnosis, but they are a way to narrow down a list of possible causes together with necessary testing. Theories relating to pain are linked to the thinking that the brain and nerves of the body are either misinterpreting the sensation of pain or overreacting to it due to chemical imbalances.

Pain is the primary symptom associated with this disorder and is commonly described as a ‘dull ache all over the body’. A warning sign for medical professionals is when a person mentions that pain has been felt consistently for at least the last 3 months. Another is that the pain is ‘widespread’. This means that pain is felt on both sides of the body, as well as on either side of a person’s waist.

Associated symptoms that are commonly noted in sufferers are:

  • Sleeping problems (such as sleeping for long periods, but not feeling rested and rejuvenated)
  • Sleep disturbance (awakening during the night and not feeling well rested during waking hours)
  • The development of sleep disorders, such as sleep apnoea and restless legs syndrome
  • Tiredness and fatigue (a lingering feeling of exhaustion which may worsen during the course of the day)
  • Mood disruptions and emotional problems (often linked to depression and anxiety)
  • Headaches
  • Difficulties with concentration and the ability to focus (also known as ‘fibro fog’)
  • Pain in the lower abdomen
  • Morning stiffness 
  • Tingling or numbness in the hands and feet
  • Painful menstrual periods (women)

Female experiencing pain at the base of her neck.

Symptoms of fibromyalgia also appear to co-exist with other painful health conditions, which can sometimes make the disorder difficult to diagnose correctly. Overall symptoms can also come and go over a period of time, making diagnosis tricky. Other common illnesses, ailments and conditions can include:

  • Headaches, including migraine
  • Irritable bowel syndrome
  • Frequent or painful urination
  • Jaw pain
  • Temporomandibular joint disorders (injured or damaged joints causing localised pain)
  • Interstitial cystitis (pronounced - in-tur-STISH-ul sis-TIE-tis – a chronic, painful bladder condition)

Diagnosing and Treating fibromyalgia

How will fibromyalgia be diagnosed?

The diagnostic guidelines used to rely heavily on the 18 trigger points. When pressure was firmly applied on these points, at least 11 painful areas would be considered as possible fibromyalgia. Now a ‘trigger point exam’ is merely considered a part of the diagnostic process. A key indication for the disorder is if a person complains of widespread pain for more than 3 consecutive months, and after being sufficiently medically assessed, there is no apparent underlying medical condition that is causing pain, a doctor may diagnose fibromyalgia.

In some instances, a primary healthcare provider may refer a person to several specialists, where they feel most necessary to assess specific symptoms, which collectively will assist in making a diagnosis. For instance, if it appears that you have arthritis, you may be referred to a rheumatologist to confirm this and assess your overall condition.

Your doctor will want to discuss your overall symptoms with you at the beginning stages of your initial consultations. You will be asked to detail any medical ailments or concerns you’ve had in the past, as well as discuss (as much as you know) any that have affected a relative in your family. Your doctor will also ask you a series of questions to gain a clear understanding about your current symptoms. In addition, he/she will ask you about any medications or supplements you are currently taking or have recently taken.

You may be asked if you have recently been through a traumatic event that has affected you either in a mental or physical capacity. Sometimes conditions such as post-traumatic stress disorder (PTSD) or an event such as a car accident can lead to fibromyalgia.

You are also likely to be asked about your sleeping habits and whether or not you feel rested. If you do not, your doctor may ask you to rate how your ill-rested state is affecting various areas of your life, as well as your overall mood.

From there your doctor will conduct a full physical exam. Part of the exam will be to assess your trigger points and the degree of discomfort you are experiencing in each area of the body. Your doctor will also be taking note of your overall appearance and noting anything that may be helpful in making a diagnosis. If you appear to be extremely tired, for instance, you may be asked about your sleeping habits and whether you are experiencing any stress or depressive emotional problems.

A neurological exam may follow a physical to test the responsiveness of muscles and joints in the body, and if necessary, you may be referred to an appropriate specialist to investigate for further assessment.

Female doctor conducting a physical exam and checking trigger points

The basic diagnostic criteria your doctor will use will essentially address the below key areas:

  • Has the patient experienced pain in the body for at least 3 consecutive months?
  • Are the other symptoms present, such as concentration problems, extreme fatigue and a constant occurrence of waking up feeling ill-rested and tired (especially if a person is getting at least 8 hours of sleep each night)?
  • Is there no other possibility of another underlying condition that may be causing any of the symptoms being experienced?

Are there any tests involved?

Since a definite cause of this disorder is yet to be determined, there is currently no single test that can be done to definitively diagnose fibromyalgia. It cannot be detected in your blood or obviously seen on a scan or X-ray. As symptoms fluctuate (come and go) due to changes in how the brain and spinal cord process signals of pain in the body, a diagnosis cannot be done with a single test either. You may be physically assessed by your doctor and feel pain and tenderness in 11 trigger points on the body on one day, and 8 on another, for example. Neither instance can then confirm the disorder, nor rule it out altogether.

Tests may, however, be recommended and together with a collective of findings relating to your group of symptoms, contribute towards a diagnosis. Tests will help your doctor to rule out the possibility of any other known medical condition (such as rheumatic disease, mental health problems or neurological conditions) which may be causing your overall symptoms. Your doctor and other specialists will carefully assess any and every possibility, which can make a diagnosis a long process to go through.

Blood tests which may be recommended include:

  • A complete blood count (CBC)
  • Thyroid function tests
  • Measuring Vitamin D levels
  • Erythrocyte sedimentation rate
  • Cyclic citrullinated peptide test

Treatments and medications

Your treatment plan will depend on the nature of your doctor’s findings. If another condition is determined as the underlying cause of your symptoms, an appropriate course of treatment will apply.

If fibromyalgia is diagnosed, a doctor will likely prescribe medications and make specific self-care recommendations. The disorder is chronic in nature, meaning you will need to make adjustments to your lifestyle. Your doctor will stress that any recommendations they make will be to help minimise the effects of your symptoms (they cannot be cured) and assist you with being able to improve your overall health condition and quality of life. No single treatment plan currently helps alleviate all symptoms.

Pain-relieving medication (capsules)Medications will be recommended to help reduce symptoms of pain, and by extension also help to improve your ability to sleep comfortably. Medication types can include:

  • Pain-relievers: These may be over-the-counter or prescribed medications. Whatever is recommended will need to be taken with care. It is vitally important that you follow the exact dosage requirements of the recommended medication so as to avoid any nasty side-effects or develop drug dependence, which can worsen symptoms of pain over time.
  • Anti-depressants: Pain and fatigue can also be treated with certain anti-depressants and help to promote better sleep. As with pain-relievers, it is very important to adhere to controlled dosages recommended by your doctor.
  • Anti-seizure: These types of medications are normally prescribed to treat conditions such as epilepsy and pain associated with the condition. These medications may sometimes be prescribed for fibromyalgia pain related symptoms too, and help to alleviate its debilitating effects.

Self-care recommendations may include a variety of different therapies which you can consider as ways, to alleviate pain in the body or enhance your quality of life by working through other symptoms. These can include:

  • Occupational therapy: This can be useful for making adjustments to how you perform certain tasks, as well as relating to your work area. Certain things you do or put your body through, including every day movements can aggravate strain and cause additional stress and pain in the body.
  • Physical therapy: Exercises can be learned as a way to improve your body’s overall, flexibility, stamina and strength levels. Sometimes, water-based exercises are helpful for this, as well as to reduce the chances of additional strains on the body which aggravate pain.
  • Counselling: If stress is a serious concern and is aggravating symptoms, a counsellor can assist in teaching you coping strategies for dealing with the emotional and mental effects of your condition, as well as how to apply them effectively in your everyday life.

Pain and stress management can also be managed with activities such as meditation practices and yoga, although there is not enough extensive research proving these practices are 100% effective for those who suffer from symptoms of physical pain associated with chronic conditions such as fibromyalgia.

Other alternative treatment options (which may not work for everyone) can include alternative practices such as:

  • Acupuncture (this can be tried as a means to alleviate symptoms of physical pain)
  • Massage therapy (this can help to alleviate symptoms of stress and anxiety)
  • Tai Chi (this activity can help to alleviate stress, depressive symptoms and anxiety by promoting relaxation)

Living with fibromyalgia

The effects of this chronic condition can and do impact on a person’s overall lifestyle. Affecting the body, it has a direct impact on your ability to perform even the most basic of things, such as movement or even just sitting still.

As a result, adjustments to lifestyle become just as important as adhering to a very specific dosage of medication. You will need to be more mindful of a variety of different things that can impact or aggravate sensitive areas of your body. Anything and everything you do, interact with or even eat is going to impact your body in some way, shape or form.

Self-care management will include the following:

  • Stress reduction: You will need to be more mindful of things that cause you unnecessary strain or emotional stress. Anything that causes overexertion will also need to be carefully limited or avoided altogether. Stress management techniques which you can learn through counselling or medication, yoga and Tai Chi practices can help with this. Try a variety of different things and see what best works for you. The goal is to reduce your stress levels in the most comfortable way possible. If you are too restrictive with your methods, you may not accomplish your goal and your overall quality of life will take strain.
  • Learning to pace yourself: With this chronic condition, there is no point in trying to rush relief. You will have better days and you will have others where your symptoms feel worse. No treatment is likely to rid symptoms completely. Take each day as it comes and pace yourself through activities, exercises and other methods of treatment in moderation. Too much of something, even if it’s a good thing, may not necessarily do you any good. Patience and moderation will become key ways you can live your life in the best ways possible. It is important to take care not to cross a line and indulge in doing too little or being too self-limiting or restrictive, especially on days when symptoms are at their worst. Keep a healthy pace going. In time, you’ll be able to work out where your boundaries are and what you can effectively cope with. Stay positive.
  • Adjustments to exercise routines: A ‘knee-jerk reaction’ may be to want to avoid exercise for fear of exacerbating effects of pain. Your thinking may appear to be supported by experiencing pain when engaging in an exercise activity (at first). Participating in an exercise activity at a gradual pace, on regular occasions can actually help to build strength, stamina and ultimately alleviate symptoms of pain. Effective exercises that promote well-being and help alleviate pain, are low aggravating physical activities (low-intensity) such as walking, biking, swimming and water aerobics. Try them all or one or two and see which ones work best for you. The best-case scenario will be a selection of activity that reduces pain and stiffness, alleviates stress and gives you a better sense of control over your condition. A physical therapist can also help with stretching, posture and relaxation exercises and techniques which you can practice at home to help your symptoms of pain as well.
  • Getting enough sleep: Tiredness and fatigue is the second most complained about symptom of fibromyalgia other than physical pain. Finding ways to ensure sufficient sleep is a big one to find a solution for and can have a dramatically improved effect on your health overall if you can find a means to achieve this. Good sleeping habits are essential. If going to bed and getting up at set times helps, stick to it. If daytime napping does not help you to feel adequately rested, refrain from doing so. Do what you can to make your bedroom an appealing sleep sanctuary. Sometimes keeping your bedroom cool, dark and quiet helps. You might also find that distractions, such as a television are best kept out of your bedroom. You can make it a rule that your bedroom is reserved for sleeping only and is not a place for late-night series watching.
  • Watching what you eat: Food is fuel. Food can also have inflammatory effects and worsen physical pain. Adopt healthier and more nutritious foods in your diet that promote healing and provide nourishment. Avoid foods that aggravate your digestive system, and limit others, such as caffeine, that can have poor effects on your overall health. Caffeine can compound stress, as well as stimulate the heart and central nervous system, which can aggravate symptoms of anxiety, nervousness and insomnia. There is no specific diet that is recommended for this condition. If your diet is lacking something you’ll feel worse off and your symptoms may increase in frequency and intensity. Healthier options and plenty of water should leave you with more energy and an improved overall condition. Listen to your body and consume more of what makes you feel good and helps you maintain a healthy weight. Avoid or limit what does not.

Other tips for coping with the condition

Young man in headphones listening to music (de-stress)

  • Relaxation and ‘me-time’: You may find that the need to achieve balance in your life is necessary on a daily basis. To help combat your health (physical) challenges, find things that give you a little bit of a ‘time-out’ each day. This helps reduce stress levels and feelings of anxiety. Music or some time engaging in a hobby can be effective ways to deviate the mind and promote relaxation. A hot bath can also help relax tense muscles in the body, and also alleviate mild pain. If you have difficulty getting in and out of a bath tub, a regular sauna can have the same effect. You can make you own by placing a stool in a closed shower to soak up a little moist heat. This can sometimes help promote a better night’s sleep too.
  • Keep a notebook: Problems with short-term memory can be solved by keeping a pen and pad of paper handy. To-do lists can help you to remember things you wish to do during the day, as can shopping lists, reminders of special occasions, names and important phone numbers or addresses. You can also use a journal to keep track of your symptoms or activities and mood changes. If you’re unsure of your pain triggers, for instance, a journal can help you and your doctor to determine what may be worsening your symptoms. For some cold or humid weather, or too little or too much physical activity may appear to trigger pain. In this way, you can adopt better coping strategies that alleviate symptoms.
  • Finding a compromise in your place of work: Earning a living can prove a little tricky at times. You may find that long days exhaust you and add to your symptoms of pain. It may come down to your choice of career or working environment. If possible you could also work out a compromise with your employer try and work from home on a part-time basis to ensure more productive working hours in your day. You can ensure that wherever your working environment is, that you rearrange it in such a way that it places the least amount of stress on your body as possible. You can also help your employer and colleagues better understand the effects of an environment on your body (from a medical perspective) and why you need things in a certain way in order to be at your most productive.
  • Communicate and find support: A chronic condition can be taxing on a person mentally and emotionally. Some days, challenges and difficulties can be downright overwhelming. It’s okay to have down moments and not always be ‘wearing a happy face’. Those closest to you will be able to understand why if you don’t shut them out. Symptoms of fibromyalgia may be more debilitating for you than may be physically apparent to others around you. Talk to your loved ones and help them to understand how your condition affects you on a daily basis. You can also seek out support groups that help individuals to cope with chronic pain and fatigue. A group that provides adequate emotional support can help to make you feel less isolated and on your own.

Support group

Common complications and risk factors

Those at higher risk for fibromyalgia include:

  • Females: The disorder appears to be more prominent in women (between the ages of 25 and 60) than in men – comprising up to 90% of cases diagnosed. To date there is no known reason for this, but genetics are suspected as a possible reason.
  • Family history: Relatives with similar symptoms or who have been diagnosed with fibromyalgia themselves, have been noted in those with the condition.
  • Related or similar health conditions: Conditions such as rheumatoid arthritis or osteoarthritis, and even lupus can sometimes lead to the development of fibromyalgia.

Complications which can arise include:

  • Disturbed sleep or lack of sleep
  • Sleep apnoea or insomnia
  • The inability to effectively function at work, school or in your personal (home) life
  • The development of mood disorders, such as anxiety or depression

Fibromyalgia misconceptions

What is the most common misconception about this disorder?

Those who suffer from this condition struggle with touch and pressure that is applied to the body (i.e. They have a heightened sensitivity to pain). To anyone else, there appears to be nothing physically wrong with a person. Pain intensity also varies from day to day.

The biggest misconception about the condition relates to the lack of understanding around what actually causes it. Initially, this condition was dubbed as something that was ‘all in your head’ and actually didn’t exist. The nature of this condition is both physiological and neurochemical, which does make it a difficult condition to understand and research. There is still a fair amount of grey area when it comes to understanding how this condition develops, why and the best ways to manage it.

It's a frustration point for both patient and medical professional. Traditional treatment approaches aren’t able to cure this condition, and there appears to be no simple fix to achieve wellness again for anyone who has fibromyalgia (a cure). It’s a constant process affecting the quality of someone’s life and neither a patient or medical professional can every really get the better of it for good. That said, it’s not impossible to make some degree of comfort possible, but it takes time, patience and dedication from everyone involved. Every small step makes a difference.

More and more medical professionals are researching this condition, and so misconceptions are falling away. Fibromyalgia is now considered a real problem. Researchers are looking to find a definite cause. If they can do this, diagnosis and treatment is sure to be easier and more effective.

Is there a cure for fibromyalgia?

Can you ever get better? Until medical research can determine a cause for this condition and other extensive research is done into how best to diagnose and treat it, you may never be cured of this condition. The best course of action is to manage your symptoms on a daily basis. The most effective combination for symptom management to date is the correct use of medications, lifestyle changes and self-care strategies.

The most commonly seen condition triggers which have been noted during thorough research appear to be related to an existing illness, trauma (physical or emotional) and genetics. A mixture may increase your risk of developing the condition, but this is still to be precisely determined.

What is ‘fibro fog’?

Business woman struggling to concentrate (focus) at work

Trouble with concentration as another complaint related to this disorder has been dubbed ‘fibro fog’. Many feel like they exist in a constant haze and find it difficult to focus throughout the day, every day.

Chronic pain and a lack of sufficient sleep and rest are some of the main reasons this can happen.

Following the treatment plan and recommendations made by your doctor can help to alleviate the intensity of this feeling and thus reduce the fog sensation over time.

Is restless legs syndrome common in those managing fibromyalgia?

Discomfort in the legs, especially below the knees is common in those suffering from this disorder. Pain is often problematic during the night and can be intense for many. Along with pain a person have ‘feel the need’ to move their legs around in order to feel more comfortable. This kind of pain is known as ‘restless legs syndrome’. Pain and the sensation of restlessness is disruptive for a person’s sleeping habits and can wake them up at night.

Is swelling, numbness and tingling sensations also common for those with fibromyalgia?

A person with fibromyalgia may also complain of swelling, tingling and sometimes numbness, particularly in the hands, arms, legs and feet. These are considered neurological complaints and do not currently have a medically clear cause.

Sufferers generally notice these sensations (known as paraesthesia) first thing in the morning, along with morning body stiffness. These sensations can, however, occur at any time, and in irregular patterns for short periods of time (i.e. a few minutes) or in some cases, constantly.

 

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