Imagine that one day you awake and your body aches all over.

One day worth of this pain may only indicate exercise or strained muscles. However, imagine that this achy feeling persists for years. You cant sleep well, often have a headache, and no matter how sunny it is outside your depression makes you want to shut the blinds and lie in the gloom of your room. Over the counter pain medications barely work and your life seems to be losing its quality. You may constantly feel as though you always have the flu (Wolters Kluwer, 2010). Individuals with fibromyalgia can experience this every day for years before they are diagnosed and are able to receive treatment. The first recorded mentions of fibromyalgia appear in the early 1700s. Symptoms of the disorder were shown in the 1800s by both Florence Nightingale, who helped develop nursing as we know it today, and Charles Darwin, who was a figurehead in evolution and wrote The Origin of Species. The name fibromyalgia did not actually arise until 1976 and there were various names, such as muscular rheumatism and fibrositis, for the disorder prior to the current name (Inanici and Yunus, 2004). The disorder has many different symptoms associated with it and because there are so many fibromyalgia is considered by some to be one of the most difficult pain conditions to treat (Moore et. al) . This could possibly be because although symptoms of the disorder have been around since the 1700s, the earliest clinical study didnt take place until the 1980s (Inanici and Yunus, 2004). Even with recent advances in the medical world studies are still ongoing. This accounts for the lack of a firm understanding of what causes fibromyalgia. It also explains why there is not a firm treatment for the disorder. It has been estimated that fibromyalgia affects some 5 million Americans (NIAMS). Roughly 2% of all people are diagnosed by the time they are 20 years old and about 8% are diagnosed by the time

they are 70 years old (Goldenberg, 2012). Roughly 80-90% of all people diagnosed with fibromyalgia are women people with a family history of fibromyalgia are more likely to be at risk themselves (Moore et. al; NIAMS). This paper will discuss the possible causes, current treatment research, and symptoms surrounding fibromyalgia. The symptoms produced by fibromyalgia are very diverse and vary from case to case. Many of the symptoms are shared by other diseases and disorders and diagnosis of fibromyalgia often comes only after other medical problems are ruled out. Rheumatoid arthritis and osteoarthritis are both similar to fibromyalgia because of widespread pain. For these diseases the pain occurs mostly at the joints. Hypothyroidism is also a disorder similar to fibromyalgia. This disorder involves pain and sleep disturbances that can be confused with fibromyalgia. Because the number of medical problems similar to fibromyalgia is so high, the process of ruling out other problems can take years and individuals most likely will not be properly treated until the actual diagnosis occurs. The most common characterizing symptom of fibromyalgia is widespread chronic musculoskeletal pain (Mayo Clinic). In order for pain to be widespread and chronic it needs to occur above and below the waist and on both sides of the body. The pain also needs to last longer than three months (Gran, 2003). The pain associated with fibromyalgia is not degenerative or progressive. It will not get worse over time and in fact many people will feel relief after some time (NIAMS). Psychosocial symptoms include fatigue, depression, and anxiety. Somatic syndromes include restless leg syndrome, irritable bowel syndrome, temperomandibular joint disorder and tender points (see figure 1) (Mayo Clinic; NIAMS).

Figure 1: The dark circles in the picture represent the tender points on the human body used to diagnose a patient with fibromyalgia.

Tender points are areas of the body that, when pressure is applied, produce pain in people with fibromyalgia. In the past these points were used to diagnose fibromyalgia once other disorders had been ruled out. The American College of Rheumatology, whos main goal is to improve the field of rheumatology, stated that 11 tender points needed to be present for a doctor to diagnose an individual with fibromyalgia (Goldenberg, 2012; NIAMS). This practice has since been partially discarded because many people do not have the required number of tender points but may still be diagnosed with fibromyalgia. The symptoms of fibromyalgia typically present themselves in middle adulthood (American College of Rheumatology; NIAMS) but may become apparent as early as childhood (NIAMS). All patients diagnosed with fibromyalgia suffer a reduced quality of life. It is entirely possible that the pain felt by patients may be great enough to prevent them from working. For these people it is imperative that treatments be found. In order to create the best treatment, the cause of the disorder needs to be found.

Researchers do not have a definitive answer as to what causes fibromyalgia. There are many hypotheses but none of these have been proven yet. It is believed that genetics play a part in the emergence of fibromyalgia. This is supported by the fact that women and people with a history of fibromyalgia in their family are more likely to be diagnosed with the disorder (Mayo Clinic). No specific gene has been targeted yet to be responsible for fibromyalgia, however, because there are many genes in common between individuals with the disorder the hypothesis still exists. For many individuals the symptoms of fibromyalgia do not emerge until an emotionally or physically traumatic experience has occurred. An infection, accident, PTSD, injury, or other emotionally or physically traumatic event could initiate fibromyalgia symptoms. It is believed that the pain involved with the disorder is caused by a low tolerance for pain (Mayo Clinic). An injury to tissue caused by a traumatic event would cause repeated stimuli for pain. This would in turn be the cause for a lowered tolerance. Pain is detected by nociceptors that are found throughout the body. A stimulus such as being pricked by a needle will activate these nociceptors and stimulate a generator potential which will in turn create an action potential. This action potential will travel through the pain pathway, using neurotransmitters, until it reaches the brain and is processed as pain. Nociceptors arose through evolution to prevent injury. The overstimulation caused by fibromyalgia, however, is maladaptive and has no use in survival. If tissues are damaged or in danger of being damaged the nociceptors will fire and the resulting pain will reduce or prevent the action that caused it (Lamont, Tranquilli, and Grimm, 2000). The two main types of nociceptors are A-fibers and C-fibers. The A-fibers are classified as fast pain pathways. The pain associated with these fibers is usually sharp and specific. C-fibers are classified as slow pain pathways. A dull, throbbing pain is

generally produced by these fibers and often lasts much longer than fast pain. In fibromyalgia the threshold for activating a generator potential is lowered and more generator potentials are produced. This releases more neurotransmitters, such as substance P and neurotensin, and the number and intensity of action potentials increases. When the pain threshold is reduced allodynia can arise. Allodynia is defined as an increased response to a stimulus caused by a decreased threshold. When this occurs even a light pressure that would normally cause no reaction can cause pain pathways to react strongly. This heightened response is what causes the increased amount of pain in a fibromyalgia patient. Researchers are still unsure as to whether the symptoms of fibromyalgia are from fibromyalgia itself or another underlying disorder (Huser et. al). There are speculations that the loss of gray matter in the brain could cause the symptoms of this disorder (Kuchinad et. al). A loss of gray matter can alter the way that information is interpreted in the brain. A misinterpretation could cause a small stimulus to produce a large response. A low pain threshold in combination with this reaction could cause the pain felt by many people with fibromyalgia. No singular treatment has been found for fibromyalgia. Because there is such a range of symptoms it is very difficult to design a miracle drug that will heal them all. The National Institute of Arthritis and Musculoskeletal and Skin Diseases, which supports research based on musculoskeletal diseases, suggests that patients take a team approach with your doctor, physical therapist, and other health professionals. It has been found that massage, movement therapy, and chiropractors can aid in the relief of symptoms caused by fibromyalgia. Chiropractors can often help with the pain of

fibromyalgia through tissue manipulation. It has been found through a study by Blunt

and associates (1997) that chiropractics can improve the range of motion for the back and pelvis and can also lower pain levels in their clients. Using a combination of chiropractics and drugs can reduce pain greatly. Antidepressants are largely used to manage symptoms. Drugs such as duloxetine and milnacipran have been approved by the FDA to treat fibromyalgia (NIAMS). These are both antidepressants and affect the levels of serotonin and norepinephrine in the brain. When the levels of both of these hormones are raised pain is decreased. Because of this effect both depression and pain can be treated by antidepressants. Antidepressants have also been found to improve the quality of sleep that individuals receive. Analgesics can be used to reduce the pain felt by individuals. These drugs work directly on the pain pathway of the body and inhibit the effect of neurotransmitters used in pain transmission. Neurotransmitters such as enkephalins and endorphins can be used to reduce pain. Opiates bind to the receptors used by pain transmitting neurotransmitters and block their effect (Lamont, Tranquilli, and Grimm, 2000). Opiates tend to be addictive, however, and are prescribed less often than other analgesics (NIAMS). Pregabalin is a drug that reduces the activity of neurons involved in the pain pathway. This drug, known by many as Lyrica, is most often prescribed for managing the pain caused by fibromyalgia symptoms. It can also improve sleep in individuals. If interrupted sleep is a main problem for a person with fibromyalgia there are a number of drugs approved to improve sleep. Cyclobenzprine, amitriptyline and gabapentin are FDA approved to improve sleep (American College of Rheumatology). Along with drug therapy it is common for individuals to undergo cognitive behavioral therapy. This therapy will change the patients perception of pain and with a change in outlook, pain can be decreased. Depression can also be helped by cognitive behavioral therapy. An individual who undergoes this therapy can experience

an increased outlook on life, which can make it more bearable. Exercise is highly stressed for people who have fibromyalgia. Exercise has been found to reduce the pain produced by tender points and strengthen the muscles in the body. This strengthening is seen as the main cause to the reduction in pain (Goldenberg, 2012). Often when people are diagnosed with fibromyalgia the pain makes it extremely uncomfortable for them to exercise. However, because it works so well it is highly recommended by professionals. Unfortunately, not every person who has symptoms of fibromyalgia looks for or receives treatment. Those who dont look for treatment suffer from their symptoms. Those who do look for treatment have to wait for until they are diagnosed to receive proper treatment. Because the first studies on fibromyalgia were not done until the 1980s doctors were not very knowledgeable about the disorder for some time. Some doctors, when they could find nothing else definitively wrong with their patient, decided that the pain was imaginary and that the patient was creating it in their head (NIAMS). Once a person discovers that they have fibromyalgia it is often best that they find a specialist who can help with their treatment. Rheumatologists are doctors who specialize in the rheumatic diseases and can help patients with the pain of fibromyalgia. There are doctors other than rheumatologists, however, that can help with fibromyalgia symptoms. Research is ongoing to determine the effects of different therapies on the symptoms of the disorder. There are many different studies that revolve around the cause and treatment of fibromyalgia. Studies of the brain have shown that gray matter loss and a decrease of brain volume occur in individuals with fibromyalgia (Kuchinad et. al). It is still uncertain whether these are causes or symptoms of the disorder. The studies of

treatment methods vary in methodology. One such treatment is repetitive transcranial magnetic stimulation, also known as rTMS. rTMS applies a series of electro-magnetic pulses to the left side of the brain in the hopes of reducing chronic pain in patients. The chemistry of the brain changes due to this stimulation. A study by Passard et. al revealed that rTMS causes a significant long-term decrease in the pain felt by individuals with fibromyalgia. The study also found that sleep became more restful for many people who underwent rTMS treatment. Antidepressants have been a large focus of studies trying to reduce fibromyalgia symptoms (Huser et. al). It has been found that antidepressants can produce a significant decrease in pain, sleep disturbances, and depression. They have not, however, been found to reduce fatigue in study participants (Huser et. al). Due to the reduction of many symptoms caused by fibromyalgia, antidepressants are largely used to treat symptoms. It is unknown whether antidepressants can help with symptoms long-term and many doctors are hesitant to prescribe both antidepressants and painkillers for long periods of time in order to prevent dependency. In both of the studies cited long-term reduction of symptoms was seen and the quality of life increased for the individuals that were involved. Fibromyalgia is not a disorder that can be cured easily with drugs and therapy. There are many symptoms that all require different types of treatment and receiving all of these treatments is not practical. For the number of people who suffer from fibromyalgia there is very little information that is constantly presented to people. People are reminded of cancer and obesity frequently because people die of these medical problems. Because fibromyalgia is not killing people and there are no death rates, there is very little action surrounding the disorder. The National Fibromyalgia

Research Foundation (NFRF) is a foundation that gives individuals a place where they can learn about their disorder, find treatment options, and learn of what research is being done. Because fibromyalgia can be such a disabling disorder it is not easy to live with. Foundations such as NFRF and the National Fibromyalgia Association (NFR) give people a place to learn about their disorder and find the best methods of treatment for their specific symptoms. The NFR website also has a chat room where individuals can talk to other people with fibromyalgia and this can act as an understanding support group for those who need the extra support. Within the next few years it is hopeful that the main cause of fibromyalgia will be determined. When this finally happens an allencompassing cure can be found.