The Fibromyalgia Syndrome (FMS) is a soft-tissue, pain amplification disorder that can cause significant functional impairment. It is a common non-articular, non-degenerative affliction causing widespread non-dermatomal pain in fibrous tissue and muscles. Concurrent fatigue that is not relieved with rest, and stiffness not relieved with activity is present.5,6,8,9

ASSOCIATED SYMPTOMS
Other concomitant symptoms may include irritable bowel, headache, cold sensitively, atypical patterns of paresthesia, exercise intolerance, anxiety, depression, irritable bladder, dysmenorrhoea, bruxism, and sensitivity to cold, weather changes, noise, bright lights and cigarette smoke. 12 The terms firbrositis, myositis, fibromyositis, myofasical pain syndrome, psychogenic rheumatism, generalized tension myalgia, generalized nonarticular rheumatism, and generalized soft tissue rheumatism have all been discarded as these each denote a once assumed cause but since unproven etiology.8

INCIDENCE
Conservative estimates place its prevalence in a general context of “widespread pain” at 10-15% of the Canadian adult population. 6 In North America, 15-20% of patients treated in rheumatology practices have FMS with 90% of them being women with onset beginning between 29-37 years of age.2 FMS is not a disorder specific to developing countries, nor is it a racially selective disorder. 5

CAUSE UNKNOWN
Many authors believe that FMS has a multifactorial etiology. This can include abnormalities of deep non-rapid eye movement sleep, irregularity of neurobiochemicals (primarily serotonin, cortisol, growth hormone and substance P), poor aerobic fitness, viral infections, loss of sympathetic nervous system control, local tissue factors (including cell damage, decrease voluntary muscle strength and low serum levels of somatomedian C), physical trauma and psychological factors such as high levels of stress, anxiety and depression.1, 2,8,10

DIAGNOSIS
As no etiologic agent has been identified, FMS is therefore a diagnosis of exclusion when no other medical disease can explain the presenting symptoms. 12 According to the ACR, diagnosis requires a history of widespread pain (not just tenderness) for greater than three months, with pain on digital palpation in at least 11 of 18 specific bilateral tender points at the occiput, trapezius, supraspinatus, anterior low neck, second rib, medial knee, lateral elbow, gluteus, or greater trochanter.5, 10 Yet, a chronic pain sufferer with fewer than 11 tender points may experience significant morbidity, which indicates low sensitivity of the ACR criteria.12

TREATMENT APPROACHES
Since FMS is a disease of chronic pain, it is inevitable that feelings of helplessness, depression and loss of control are felt, at some time, by sufferers.3 Exercise and education reinforces active participation of the patient in the management of their disease and teaches more effective ways of coping with pain. 7 Most authors concur that a multimodal plan of management is required. This optimally includes supervised aerobic exercise participation, symptom-based medication management, and cognitive-behavioural therapy.4, 11

The modern day Chiropractor and Physiotherapist whose goal is to maximize function and reduce impairment to limit disability in patients with musculoskeletal conditions, through the use of manual therapeutic techniques, exercise prescription, and education, is ideally suited to co-manage patient’s with FMS. Furthermore, exercise prescription and education about correct posture, functional activity, relaxation, energy conservation and fatigue management can help alleviate the aforementioned negative feelings.7 Without multidisciplinary cognitive based therapy and medical management, it is unlikely that a Chiropractor or Physiotherapist can successfully manage all aspects of this disorder.

Owing to the chronicity of this condition, it is unusual for anyone to come off treatment completely; thus, particularly with this patient population, it is advisable to move away from purely evidence based care, as many treatments may never be formally studied and the potential for benefit due to the placebo effect is significant.9 It should be remembered that due to the multifactorial etiology, no effective treatment has been universally successful.

IS DIAGNOSIS HELPFUL?
Some medical authorities argue that diagnosis is harmful, as it may make suffers feel more disabled than they are; however, others argue that a firm diagnosis is relieving in that the patient no longer fears fatal or progressive diseases and is more inclined to participate in effective treatments. Through promoting independence through exercise, and education about correct posture, functional activity, relaxation, energy conservation and fatigue management, this reinforces active participation of the patient in the management of their disease and teaches more effective ways of coping with pain.7

REFERENCES
1. Bennett RM, McCain GA. Coping successfully with fibromyalgia. Patient Care 1995; 26:29-42.
2. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome, I: medical and pathophysiological aspects. Pain 1991; 44:227-239.
3. Boissevain MD, McCain GA. Toward an integrated understanding of fibromyalgia syndrome, II: psychological and phenomenological aspects Pain 1991; 44: 239-248.
4. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD003786. DOI: 10.1002/14651858.CD003786.
5. Fan PT, Blanton ME. Clinical features and diagnostics of fibromyalgia The Journal of Musculoskeletal Medicine 1992; 9:24-42.
6. Goldenburg DL. Fibromyalgia syndrome a decade later: what have we learned? Archives of Internal Medicine 1999; 159: 777-85.
7. Gustafsson M, Ekholm J, Broman L. Effects of a multiprofessional rehabilitation programme for patients with fibromyalgia syndrome. Journal of Rehabilitation Medicine 2002; 34: 119-127.
8. Krsnich-Shriwise S. Fibromyalgia syndrome: an overview. Physiotherapy 1997; 77:68-75.
9. Meisler JG. Toward optimal health: The experts discuss fibromyalgia. Journal of Women’s Health and Gender-Based Medicine 2000; 9: 1055-1060.
10. Millea PJ. Treating Fibromyalgia. American Family Physician 2000; 62: 7.
11. Quisel A, Gill J, Walters D. Exercise and Antidepressants improve fibromyalgia. Journal of Family Practice 2004; 53: 280-291.
12. Schneider MJ, Brady DM. Fibromyalgia Syndrome: A New Paradigm for Differential Diagnosis and Treatment. JMPT 2001; 24: 529-54.