What is Fibromyalgia and what are its symptoms?
Fibromyalgia (also called fibrositis or fibromyositis) is a syndrome that causes chronic, sometimes debilitating muscle pain and fatigue. The pain occurs in areas where the muscles attach to bone or ligaments and is similar to the pain of arthritis. The joints themselves are not affected, however, so they are not deformed nor do they deteriorate as they may in arthritic conditions. The pain typically originates in one area, usually the neck and shoulders, and then radiates out. Most patients report feeling some pain all the time; and many describe it as "exhausting". The pain can vary, depending on the time of day, weather changes, physical activity, and the presence of stressful situations; it has been described as stiffness, burning, radiating, and aching. The pain is often more intense after disturbed sleep. The other major complaint is fatigue, which some patients report as being more debilitating than the pain. Fatigue and sleep disturbances are, in fact, almost universal in patients with fibromyalgia, and if these symptoms are not present, then some experts believe that physicians should seek a diagnosis other than fibromyalgia. Between a quarter and a third of patients experience depression, and disturbances in mood and concentration are very common. (In one study 46% of patients had been diagnosed with depression in the past.) Fibromyalgia patients are also prone to tension or migraine headaches. Other symptoms include dizziness, tingling or numbness in the hands and feet, and gastrointestinal problems, including irritable bowel syndrome with gas and alternating diarrhea and constipation. Some patients complain of urinary frequency caused by bladder spasms. Women may have painful menstrual periods.

What causes Fibromyalgia?
Fibromyalgia is sometimes categorized as primary or secondary; primary fibromyalgia is the more common form.

Causes of primary Fibromyalgia.
The cause or causes of primary fibromyalgia are not known; this condition is also sometimes referred to as idiopathic fibromyalgia. Many experts believe that fibromyalgia is not a disease but rather a dysfunctional disorder caused by a constellation of biologic responses to stress in individuals who are more susceptible to such stress because of negative personal histories or genetic factors.

Family factors
One recent study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. There were no differences in psychological disorders among those offspring with fibromyalgia and those who did not develop it. Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain--with about 10% reporting fibromyalgia. Close-knit families, oddly enough, were more likely to be associated with severe cases of childhood fibromyalgia. One noted that the severity of the disorder increased in children whose parents were less able to cope with their children's pain. It is not clear if genetic or psychological factors or both are involved.

Chronic sleep disturbance
Some experts believe that disturbed sleeping patterns may be the original precipitating factor for many cases of fibromyalgia pain. In one study, volunteers who did not have fibromyalgia reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation and pain.

Abnormalities in the brain
Studies of hormonal, metabolic, and brain chemical activity in fibromyalgia patients have shown a number of abnormalities. Brain scans of fibromyalgia patients have revealed reduced blood flow to certain regions of the brain related to pain sensation. Of particular interest to researchers are possible abnormalities in the brain system known as the hypothalamus-pituitary-adrenal gland axis, which controls important functions, including growth, sleep, response to stress, and depression. One research target is the hormone somatomedin C (also called insulin-like growth factor), which is produced by the pituitary gland in the brain during deep sleep and is responsible for communicating information about pain-producing stimuli to the brain. Very high levels of somatomedin C have been detected in the spinal fluid of fibromyalgia patients. Such increased levels may cause a heightened sensitivity for pain in such patients, who can experience pain even after mild muscular activity. This causes patients to reduce their physical activity, which, in turn, results in muscle weakness, leading to a perpetual loop of muscle atrophy, and increasing pain with less and less physical exertion. The pain also causes on-going sleep disturbance. Excess somatomedin C may be due to a genetic defect or may be derived from early unhealthy sleep habits that, over time, cause hormonal and brain chemical imbalances. 

People with fibromyalgia also tend to have low levels of the neurotransmitter serotonin and its precursor, an amino acid called tryptophan. (A neurotransmitter is a chemical in the brain that serves as a messenger between neurons.) Low levels of both these chemicals are associated with depression and other symptoms of fibromyalgia, including gastrointestinal distress, migraine headaches, and anxiety. Some experts believe that migraine headaches and fibromyalgia are related because of possible defects in the systems that regulate serotonin and another neurotransmitter, epinephrine (commonly called adrenaline). Low levels of magnesium have also been noted in both fibromyalgia and migraine sufferers.

Autoimmunity
Fibromyalgia resembles a number of rheumatic disorders that are known as autoimmune disorders, including rheumatoid arthritis and systemic lupus erythematosus. These diseases occur when a defective immune system produces factors known as autoantibodies, which attack proteins in the body's own tissue, mistaking them as antigens (foreign proteins). Recently, researchers have identified certain autoantibodies in many fibromyalgia patients that affect neurologic and hormonal systems. There is no strong evidence, however, that a faulty immune system is a primary cause of fibromyalgia.

Post-Traumatic Stress Disorder
One study has indicated that the incidence of sexual and physical abuse is higher in female patients with fibromyalgia than in the general population. This could indicate that posttraumatic stress syndrome may play a role in the development of this disorder in some patients. Post-traumatic stress disorder (PTSD) is an anxiety disorder that is a reaction to a specific traumatic event. Symptoms of this condition, which can occur for years after the traumatic event include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. There is some evidence that PTSD actually results in changes in the brain, possibly from long-term overexposure to stress hormones.

Hypervigilance
It has been suggested that some factor or a combination of factors, such as a genetic susceptibility, biologic abnormalities, chronic sleep deprivation, or trauma, causes generalized hypervigilance , an amplification of sensation. People with this condition are oversensititive to external stimulation and are preoccupied with the sensation of pain. One study compared three groups of individuals: those with fibromyalgia; patients with rheumatoid arthritis; and people without these disorders. They were given a questionnaire to assess their response to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant and most attentive to such stimuli.

Muscle Cell Abnormalities
Early research suggested that fibromyalgia is basically a muscular disorder. One relatively recent study reported that fibromyalgia patients had lower levels of the muscle-cell enzyme phosphocreatine and adenosine triphosphate (ATP). Such enzymes regulate the ebb and flow of calcium in muscle cells, an important component in their ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells and the muscle remains contracted. Such abnormal enzyme levels could derive from signals in the brain, although some researchers have observed overly thickened capillaries in the muscle tissue of fibromyalgia patients, which could produce lower enzymes levels as well as reduce the flow of oxygen-rich in the muscle tissue. Nevertheless, most research is now showing that fibromyalgia is probably due to abnormalities in nervous or immune systems rather than in muscles.

Causes of Secondary Fibromyalgia
Secondary fibromyalgia is caused by specific disorders, including injury, ankylosing spondylitis, or surgery. The symptoms are identical to those of primary fibromyalgia but are harder to treat. In one study, secondary fibromyalgia developed in over 20% of patients who had neck injuries.

Who Gets Fibromyalgia?
Fibromyalgia is the most common cause of widespread muscular pain and affects an estimated 2% of the general population. Two thirds of patients are women, and their symptoms are more severe than men's. An increased incidence of fibromyalgia has been reported in people who have relatives with the disorder, indicating that a genetic component may cause certain people to be more susceptible to fibromyalgia. The disorder usually occurs in people between 20 to 60 years of age and peaks at age 35. In one study, however, fibromyalgia increased with age and had a prevalence of over 7% in patients between 60 and 79 years of age. A condition called juvenile primary fibromyalgia, which appears in children, is uncommon, but studies indicate that its incidence is increasing. One study found that 1.2% of school children--all girls--met the criteria for fibromyalgia. Other studies have found an even higher prevalence of fibromyalgia in children.

How is Fibromyalgia diagnosed?
Diagnostic criteria:
In spite of increasing evidence that fibromyalgia is a physical disorder, there is no unequivocal objective method for diagnosing the problem. In general a diagnosis of fibromyalgia requires the presence of at least 11 of 18 specific areas on the body that are intensely painful (not just tender) when pressed. These trigger points can be found in the following areas:
 

> On left or right side of the back of the neck, directly below the hairline;
> On left or right side of the front of the neck, above the collar bone (clavicle);
> On left or right side of the chest, right below the collar bone;
> On left or right side of the upper back, near where the neck and shoulder join;
> On left or right side of the spine in the upper back between the shoulder blades (scapula);
> On the inside of either arm, where it bends at the elbow;
> On left or right side of the lower back, right below the waist;
> On either side of the buttocks right under the hip bones;
> On either knee cap.
> On left or right side of the back of the neck, directly below the hairline;
> On left or right side of the front of the neck, above the collar bone (clavicle);
> On left or right side of the chest, right below the collar bone;
> On left or right side of the upper back, near where the neck and shoulder join;
> On left or right side of the spine in the upper back between the shoulder blades (scapula);
> On the inside of either arm, where it bends at the elbow;
> On left or right side of the lower back, right below the waist;
> On either side of the buttocks right under the hip bones;
> On either knee cap.

(Some people also experience tender points at the bottom of their feet.) To confirm the diagnosis, widespread pain, which is experienced in upper and lower and left and right parts of the body and in the spine, must persist for at least three months. Using such criteria is helpful in making a diagnosis of fibromyalgia, but it is not completely reliable and misses about 10% of patients. Because the sensitivity of tender points may vary depending on circumstances, a physician may re-check pressure points that do not respond the first time in patients who have other significant symptoms. Some experts believe that fibromyalgia can be diagnosed if only 8 to 10 tender points are identified but the patient also has at least three other relevant symptoms, including morning stiffness, fatigue, sleep disturbance, numbness or tingling in the hands and feet, or headache. Although symptoms are similar in children, some experts suggest that they often have no set number of pain trigger points. In one study, children had an average of 9.7 trigger point locations compared to the minimum of 11 in adults. In general, children with fibromyalgia most often experienced sleep disorders and diffuse pain, and less frequently headache, general fatigue, and morning stiffness.

Medical and personal history
A physician should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might be indicative of disorders other than fibromyalgia, including recent weight change, physical injuries, infectious diseases, muscle weakness, rashes, and any instances of sexual, physical, or substance or alcohol abuse. The patient should report any drugs being taken, including vitamins and over-the-counter or herbal medications.

Physical examination
Any physical examination for fibromyalgia requires that the physician press firmly on all potential trigger spots. It also includes scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.