Fibromyalgia syndrome (FMS) is a complex medical condition that affects about 5 million American people. The condition is characterized by "chronic widespread pain, fatigue, sleep disturbance, stiffness, impaired memory and concentration, anxiety and depression." (Facts of Life, 2001). Sleep disturbance and an increased sensitivity to pain follow a cyclic pattern in individuals having FMS, the result of which is a positive feedback loop. (Etiology of Fibromyalgia, 2003).
Typically, fibromyalgia affects women, especially those between the ages of 20 and 55. (Who gets fibromyalgia? 2003). Women in this age group, as also people with rheumatologic or endocrine problems (such as thyroid disease), are at greatest risk for developing fibromyalgia syndrome. Fibromyalgia can also manifest at the time of menopause, and the malaise has also been seen to exist among members of the same family in successive generations. This syndrome also sometimes affects men and children.
The cause of fibromyalgia is yet unknown, and many researchers believe that abnormalities in the central nervous system or in the functioning of the neuro-endocrine systems may be causative factors. Research is underway as to the possible triggers and the concurrent occurrence between fibromyalgia and other medical conditions such as chronic fatigue syndrome and irritable bowel syndrome. Factors that may contribute to the development of this syndrome in an individual include emotional stress, injury or trauma, muscle function, changes in serotonin levels, and a family history of fibromyalgia. (Facts of Life, 2002). Weather changes, increased physical activity, physical or mental stress, and lack of sleep, can act as triggers, inducing fibromyalgia symptoms. The individual's sensitivity to these triggers also increases progressively with continued exposure to them. It is suspect also, that infections may play a role, although there is no definite evidence. In the absence of clear evidence as to the cause of FMS, its treatment can only be limited to managing the symptoms through exercise, education, cognitive-behavioral therapy, medication and physical rehabilitation. (Facts of Life, 2002).
Historical Evolution of Fibromyalgia (FM):
Symptoms of fibromyalgia were first described in the early 1800s. Physicians recognized the signs and symptoms of what we now call fibromyalgia and used the term muscular rheumatism, to describe the same condition. It has also been called chronic rheumatism, myalgia, and fibrositis. (De Blecourt & Knipping, 2002). Yet other names have been used by the medical profession, to describe the different forms of non-articular rheumatism: fibrositis syndrome, interstitial myofibrositis, Muskelschwiele (muscle callus or welt), myogelosen (muscle gelling), Muskelh rten (muscle hardening), muscular rheumatism, non-articular rheumatism, or Weichteil rheumatismus (soft-tissue rheumatism), myofascial (pain) syndrome, myofascitis, or trigger points, and myalgia or myalgic spots. (De Blecourt & Knipping, 2002).
In the early years, physicians attributed the painful condition to the stresses and strains of modern life. They also often ascribed to it a psychosomatic origin, and some believe that it is psychological in nature. Others attributed it to an inflammation in the body's fibrous tissue. A review of the research has indicated that as many as 80% of people diagnosed with fibromyalgia also have chronic fatigue syndrome; likewise, about 80% suffer from chronic headaches; 75% have temporo-mandibular disorders, up to 60% have irritable bowel syndrome, and 33% have multiple chemical sensitivity. (De Blecourt & Knipping, 2002).
Fibromyalgia (FM) was often misdiagnosed before the 1980's, because there is no clear diagnostic procedure, either based on X-rays or through laboratory tests. There is no diagnostic marker in the blood. (Overview: What is Fibromyalgia?, 2001). Also, people with FM often look healthy. The etiology of fibromyalgia syndrome still remains elusive, and the absence of a uniform pathophysiogical basis to the condition means that it cannot be regarded as a distinctive disease.
In 1824, a doctor in Edinburgh described 'tender points' in the body. In 1880, a psychiatrist in the United States described the same conditions - a collection of symptoms consisting of fatigue, widespread pain, and psychological disturbances - and called it neurasthenia, and attributed it to physical and mental stress. (Nagy, D.K., 2002).
In 1904, Sir William Gowers used the term "fibrositis" in a paper on lumbago, to refer to the sore points found in patients suffering from muscular rheumatism. He described muscular rheumatism as an inflammation of fibrous tissue of the muscle, and explained that the inflammation in lumbago originated behind the sacrum and spread to the fibrous sheath of the sciatic nerve, resulting in widespread pain. According to Gowers, factors, which precipitate the symptoms, included exposure to cold, and acute and chronic muscular over strain. (Stonecypher, S.M., 1999).
Luff wrote about the factors precipitating fibrositis, in the British Medical Journal in 1913. He observed that the symptoms worsened when rain was in the offing, usually preceded by a lowering of atmospheric pressure. Luff explained how factors such as temperature variations, fevers, infections and accidents could act as triggers, precipitating or aggravating the symptoms of fibrositis in chronic sufferers. (Stonecypher, S.M., 1999).
Between 1970 and 1990 researchers like Yunus, Campbell and Smythe have proposed several sets of criteria for the diagnosis of fibromyalgia. Smythe (1980) defined certain diagnostic criteria such as widespread aching of more than 3 months' duration; local tenderness at 12 of 14 specified sites; skin roll tenderness over the scapular region; and disturbed sleep, with morning fatigue and stiffness. (De Blecourt & Knipping, 2002).
In 1981, Yunus defined certain obligatory criteria and some major and minor criteria for the diagnosis of what he called primary fibromyalgia syndrome. Obligatory criteria included the presence of generalized aches and pains or prominent stiffness, involving 3 or more anatomic sites, for at least 3 months. Major criteria included the presence of at least five typical and consistent tender points. Minor criteria such as sleep disturbance, anxiety, chronic headaches and the aggravation of symptoms by physical activity or by stress, were also listed. Yunus' criteria for diagnosis required that patients must satisfy the 2 obligatory criteria, as well as either the major criterion in addition to at least 3 minor criteria, to be diagnosed with primary fibromyalgia. (De Blecourt & Knipping, 2002).
Campbell (1983) devised a questionnaire to define whether fibromyalgia syndrome was present in the individual, as a kind of diagnostic measure. Patients were asked to answer in all, 15 questions, such as " I have pain in my muscles and joints" or "My pain is affected by weather," and so on. Diagnosis would be based on the responses to these questions. (De Blecourt & Knipping, 2002).
The American Medical Association (AMA) first recognized Fibromyalgia as a "true" illness and the cause of disability, in 1987. Goldenberg reported on the symptoms and treatment in 118 patients having fibromyalgia, in an article published in the Journal of the American Medical Association (JAMA), in 1987. Doctors are however still cautious before pronouncing a diagnosis of fibromyalgia, because of the lack of any clear-cut clinical evidence pointing to this condition. (Nagy, 2002)
Simons and Travell have conducted extensive research on a related condition called the myofascial pain syndrome. An international symposium on myofascial pain and fibromyalgia was held in Minneapolis, USA, in 1989. Myofascial pain syndrome is characterized by trigger points in the muscle tissues or fibers. A trigger point is defined by Travell as "circumscript tenderness, a localized twitch or fasciculation on stimulation by pressing or pinching that portion of the muscle, which contains the trigger area, and referred pain produced by pressure on the trigger point." Myofascial pain syndrome is developed when a trigger point develops in a muscle. This happens when a muscle is overworked and fatigued, chilled or severely traumatized. These factors are considered as direct causes, while other factors (other trigger points, arthritic joints, and emotional stress) are considered as indirect causes, in the sense that they create conditions that lead to the development of the triggerpoint.
The Copenhagen Declaration" on fibromyalgia was formalized at the second World Congress in 1992 in Copenhagen. Several international experts on fibromyalgia helped summarize the different aspects of the fibromyalgia syndrome, in this document. According to a review titled "Fibromyalgia: a clinical challenge" by Lorentzen, the symptoms often reported by patients suffering from fibromyalgia actually reflect the difficulties they experience in coping with various types of environmental stress. The experienced stress may lead in turn to sleep disturbances, fatigue and a low level of physical activity and fitness. This again may lead to muscle pain and tenderness. The syndrome becomes chronic because of the vicious circle that is thus set in motion. Lorentzen explains that these factors causing stress need to be identified early so that early intervention is made possible. (De Blecourt & Knipping, 2002).
Fibromyalgia syndrome is unique in many ways, but has been found to overlap with other unexplained comorbid medical conditions, including irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), temporomandibular disorder (TMD), and migraine headache. Symptoms such as pain, fatigue, disturbed sleep, anxiety and depression are common to all of these conditions, and many people who have one of these conditions also meet the diagnostic criteria for at least one other. Studies on comorbid conditions have revealed that among people with fibromyalgia, as many…