For PDF file of full report including Appendices

4.0   FINDINGS FROM THE ENVIRONMENTAL SCAN

4.1   Chronic Pain

4.1.1   Overview

Chronic pain develops over time and is considered when pain persists three months or more in duration. It is often assumed, incorrectly that the difference between the designation of either ‘acute’ or ‘chronic’ is the duration of pain. In fact, the true difference lies in whether or not physiological function returns to normal. In some cases, chronic pain can persist for different reasons beyond what originally created the chronic pain situation initially. In many instances, chronic pain syndromes are triggered by a trauma, injury or a disease. An issue, such as the extent of a trauma or augmentation in the body’s nervous system in response to the adversity creates the situation through which the body does not return to normal processes. Ultimately, physical and chemical changes take place within the body whereby chronic pain is experienced on a physical level even after the origin (if determined) of the pain is gone. In other words, the body does not have the ability to return to previous levels of homeostasis causing an on-going situation of constant or recurring chronic pain (Gatchel et al. 2007). Common chronic non-malignant pain is seen in conditions such as multiple sclerosis, chronic post-surgical pain, trigeminal neuralgia and fibromyalgia to name a few. Perhaps the most familiar chronic pain is musculoskeletal, which is sometimes referred to as mechanical chronic pain and includes osteoarthritis, rheumatoid arthritis, osteoporosis, different traumas, various injuries and other conditions.  Common areas of the body affected by chronic pain are the back, neck, chest, ribs and knee. Malignant pain stemming from various forms of cancer is beyond the scope of this report, thus the following discussion regarding chronic pain refers to non-malignant conditions (See Appendix E for a comprehensive list of pain conditions).

Historically, the research and classification of chronic pain was focused on sensory characteristics. More recently, both researchers and clinicians have broadened the scope of chronic pain to include cognitive processes, affective influence, behavioural factors and the over-riding influence of stress that affect homeostasis within the body. Estimates suggest that globally up to 20% of people suffer with chronic pain (H Breivik et al. 2005). In Canada, the National Population Survey (NPS) from 1994-95 estimated overall prevalence rates of chronic pain of 15% and 20% of the population for men and women respectively and also noted that the prevalence for chronic pain increased with age (with the exception of migraine headaches) (Tunks, Crook, and Weir 2008) . Similarly, a cross-sectional survey of 46,000 study participants conducted across 15 European countries found that 20% of the general population reports chronic pain, which is similar to other current global estimates (H. Breivik et al. 2006). The epidemiology of chronic pain produces wide estimates of prevalence in the population. Various reasons exist to explain the variations and are attributed to: the definition of chronic pain used in epidemiologic and other studies (e.g., general medical condition or pain disorder), the specific methodology used to identify cases, and the particular type of data used to produce the estimates such as self-report methods versus census data, to highlight a few.

In medicine, the biopsychological method to understanding disease involves an approach where biological, psychological and social factors all significantly impact disease. Despite numerous aspects of chronic pain disorders remaining elusive to researchers and clinicians, the biopsychological approach is well recognized as a way to provide a framework in both understanding and treating various chronic pain disorders. It is precisely the interaction of physical, emotional and social factors that can enable or exacerbate symptoms.  Furthermore, the culmination of various factors may also contribute to the on-going nature of chronic pain (Gatchel et al. 2007). Concerning the biological, recent research has examined the association between genetics and chronic pain. Simply put, an overexpression or absence of a gene can produce functional changes within the body. The components and activities within the nervous system involved in pain transmission can be affected by changes in gene expression or the augmentation of pain pathways (Gatchel et al. 2007), albeit no one gene is known to cause any specific CP disorder.

Changes to the pain processing pathways in the central nervous system or extensive tissue damage and scarring from injury can create chronic pain states that are difficult to diagnose, treat and subsequently manage. In some conditions, the severity of the pain is without explanation, in other words there is no identifiable trauma or injury to explain an individual’s suffering. Furthermore, other variables such as the environment, physical and emotional stress levels and an individual’s coping mechanisms can affect the perseverance and amount of pain experienced. Thus, chronic pain leads to a significant burden of illness for individuals, their families and society as a whole. Particular studies have demonstrated that over half the individuals suffering with chronic pain reported an interference with work, over 80% stated they also had a co-morbid condition and both the chronic pain and psychological distress accounted for increased health care utilization (Tunks et al. 2008).

The treatment and subsequent response by an individual to treatment of chronic pain is much different that acute pain. Determining both the severity of chronic pain and effective treatments are difficult to estimate. On the other hand, acute pain has an unambiguous cause such as a trauma or other pathology. The treatment of acute pain is informed by gold-standard protocols. Conversely, “[m]any chronic pain conditions lack a defined cause, are more difficult to diagnose, and are often associated with mood effects…” (Wallace and Daniel J Clauw 2005). Chronic pain treatment often does not address the pathological cause and pain often continues or returns when treatment is finished.

The focus of treatment for chronic pain is: finding the shortest pathway to reducing pain, maintenance of pain reduction for the patient, cost effectiveness for the patient (as many treatments are third party providers), the improvement on quality of life, the improvement of physical function, the impact on anxiety and mood, reducing the effect of drug side effects and a consideration of the risk-benefit of treatment for pain reduction. The underlying cause of chronic pain should be treated where possible and oral medication is a cornerstone of chronic pain treatment. Importantly and emphasized by the World Health Organization (WHO) is that there must be an emphasis on individual plan of care and that treatment approaches for chronic pain must be combined with psychological support in order to realize efficacy in reducing pain.

Various studies conducted over the past 10 years cite that individuals from all geographical areas experience undue suffering with chronic pain even though various treatments exist to relieve such pain. Importantly, a majority of the older adult population and up to one in five adults suffer with various forms of chronic pain despite effective medications (H Breivik et al. 2005). One reason for this situation is the stigma that is associated with opioid use. Many issues such as prescription abuse, addiction problems and the scrutiny of clinicians prescribing opioid medication and particularly strong opioids has resulted in low(er) prescribing patterns despite empirical evidence documenting their efficacy in treating and managing long-term chronic pain (Castro-Lopez, J. et al. 2005). Clinicians have issues to address such as the dependency surrounding opioids use, tolerance development to medication and how to supervise the patient.

Research suggests that 40%–50% of chronic pain patients also suffer from depressive disorders (Banks & Kerns, 1996; Dersh, Gatchel, Mayer, Polatin, & Temple, 2006; Romano & Turner, 1985). Epidemiologic studies have shown a statistically significant association between chronic pain and depression even though the causal order is unknown. Specifically, work done on chronic musculoskeletal pain disorders suggests that the chronic pain in fact causes the depression (Marcus, 2009). Similarly, the episode of depression onset is often stated as occurring after the onset of a particular pain disorder. Conversely, research in other patient populations has shown that previous bouts of depression were found among patients before their chronic pain disorder manifested. Despite conflicting results and the unknown nature of the causal relations between depression and CP, it is widely accepted that conditions involving pain and psychological aspects have a reciprocal impact on illness and disease (Gatchel et al. 2007).

The diagnosis, treatment and management of chronic pain are complex. Individuals must understand their condition, know the impact of lifestyle choices and develop effective coping strategies; this requires education both for clinicians and patients alike, which we cannot assume either group has from the outset. The loss of productivity and daily activity due to chronic pain is extensive. An individual’s constant management and living with chronic pain has a significant impact on one’s quality of life. Common activities such as socializing, exercising, performing at work, daily activities and getting quality rest and sleep are impacted by chronic pain. Over time, this can lead to depression, feelings of social isolation and loss of personal self-esteem. Importantly, depression is the most frequent psychological reaction to chronic pain (Taylor 2007).

4.1.2    Outline of Specific Chronic Pain Disorders

There are numerous chronic pain syndromes and the majority fall into the following categories (See Appendix E for a list of pain conditions). For illustrative purposes, three CPD: Myofascial Pain Syndrome (MPS), Neuropathic Pain (NP) and Chronic Headaches (CH) will be discussed in general to provide a macro-level orientation to different types of chronic pain. This is followed by a specific in-depth review of fibromyalgia in Section 3.3.

1. Myofascial Pain Syndrome
2. Musculoskeletal
3. Neuropathic Pain
4. Chronic Headaches
5. Fibromyalgia

Myofascial Pain Syndrome (MPS)

Myofascial pain syndrome (MPS) involves the skeletal muscles and specifically the connective tissue that covers the muscle. Specific to MPS is the presentation of referred pain, pain that occurs somewhere else in the body when particular trigger points have applied pressure. Such trigger points are nodules or taut bands of muscle that can often be felt through the skin. The pain of trigger points is associated with pain in the neck or jaw, lower back, pelvic region along with the legs and arms. The most frequently occurring symptoms are aching pain within the muscles that can either persist or get worse over time, muscle and joint stiffness, feeling of tension within specific muscles and pain interfering with restorative sleep. Most individuals with MPS can trace the origin to either an injury or an overuse of the muscles at some point. MPS often affects adults between 35 and 50 and women are more likely to develop MPS compared to men.

Specifically, myofascial pain syndrome (MPS) may be confused with fibromyalgia and often co-occurs and although MPS is very common among individuals with fibromyalgia; it is not clear if one in fact causes the other. The patient history in conjunction with the physical examination will allow the clinician to determine whether a patient has fibromyalgia, myofascial pain syndrome, or both. MPS is associated with pain from trigger points within certain muscles. Overall, the definitive differentiation between myofascial pain syndrome and fibromyalgia is made by physical examination. In some cases, MPS is treated with medication whereas other cases require a combination of physical therapy, trigger point injections and or massage therapy.

Neuropathic Pain (NP)

Neuropathic pain (NP) or nerve pain results from damage to the nervous system, including peripheral nerves, spinal cord and certain central nervous system (CNS) regions. Nearly half of all NP pain occurrences follow a trauma, inflammation or infection.  NP is caused by some alteration in the structure within the nervous system versus non-neuropathic pain, which is generally associated with lesions as opposed to changes in structure. Specific examples of neuropathic pain include trigeminal neuralgia (TGN) and shingles.  The clinical symptoms of neuropathic pain include spontaneous pain, allodynia (i.e., pain due to a stimulus that does not normally produce pain, such as soft touch), and hyperalgesia (i.e., an exaggerated response to a stimulus that is normally somewhat painful). The pain may be experienced in the local region of the nerve or in different places on both sides of the body (i.e., bilaterally). NP pain is described as burning, shooting, stabbing, piercing, and a feeling of electric shock (Gatchel et al. 2007).

A specific example of NP is a condition known as trigeminal neuralgia (TGN), a debilitating pain in the face that commonly starts without reason and begins on one side. The pain is excruciating and described as an electric shock. The onset of TGN is most frequent among older adults but does not exclusively affect the older population. TGN may flare up at any time and triggers are numerous: chewing, touch, temperature, showering or even stepping outside in the wind. The pain may pass very quickly or last several minutes. As in most chronic pain disorders, treatment focuses on reducing symptoms and may involve prescribed anticonvulsants such as gabapentin. Trigeminal neuralgia is one of many syndromes associated with compression in the neurovascular system. An artery in the brain is compressing a cranial nerve. In situations where pharmacological agents do not provide sufficient pain relief, individuals with TGN can undergo surgery and have micorvascular decompression of the artery and the trigeminal nerve. Research has demonstrated that a vast majority of surgical patients report positive improvement in pain along with the disappearance of pain in many cases (Monstad, 2009).

Chronic Headaches

Chronic headaches may be further classified as chronic migraine, cluster, trauma, tension and analgesic overuse types of headaches. Classifications are largely based on location and duration. The duration of chronic head pain is an important diagnostic factor and headaches lasting more than 2 hours are most common among cluster, migraine and tension headaches. Additionally, the rate of recurrence, the severity and whether or not it is on one side of the body or both are all important characteristics when making a diagnosis. The causes of headaches are numerous and include other conditions such as glaucoma, temporomandibular joint dysfunction or trigeminal neuralgia. Additionally, some lifestyle factors play a role in trigger headaches such as alcohol, smoking and for some people certain foods such as chocolate. Finally, particular psychological causes such as depression, increased stress levels and sleep disturbances are associated with headaches. In most cases, chronic headaches are treated with oral analgesics. However, if an individual experiences severe recurring episodes, a preventative pharmacological agent along with modifying certain lifestyle factors may be necessary (Schürks, Diener, and Goadsby 2008)(Marcus 2009)(May 2005).

4.2   A Focus on Fibromyalgia

4.2.1   History of Fibromyalgia

As far back as the early 1900’s, what we now call fibromyalgia was described as a disorder of the musculoskeletal system thought primarily caused by characteristics of inflammation of fibrous tissue and was referred to as fibrotisis (Wood, Patrick 2008) (Chakrabarty and Zoorob 2007). In the 1970’s, the term fibromyalgia was introduced and the condition became known as a pain disorder of widespread generalized pain and tenderness on palpation at specific points on the body (Podolecki, T., Podolecki, A., Hrycek, A. 2009).

4.2.2   What is Fibromyalgia?

fibromyalgia is a poorly-understood chronic pain syndrome, is characterized by widespread musculoskeletal pain, nonrestorative sleep, fatigue and psychological distress with specific regions of localized tenderness. This syndrome is considered one of several 'central' pain syndromes that are common in the general population (Dadabhoy, D., and Daniel J. Clauw 2006). The constellation of symptoms of fibromyalgia all appear in the absence of other pathologies (Abeles, M., Solitar, B., Pillinger, MH. et al. 2008) (Aryeh, M., Pillinger, Micheal H., Solitar, Bruce M. and Micha Abeles 2007). fibromyalgia often occurs together with other chronic pain disorders and individuals with fibromyalgia are between 2 and 7 times more likely to have one or more of the following co-morbid conditions: depression, chronic fatigue syndrome, irritable bowel syndrome, systemic lupus erythematosus, headache, anxiety and rheumatoid arthritis.  (Weir, Peter T., Harlan, Gregory A., Nkoy, F. et al 2006).

4.2.3   Epidemiology

Fibromyalgia is the most common chronic pain syndrome encountered in general medicine and rheumatology. Historically, the conceptualization of the syndrome and our understanding of the process of fibromyalgia have impacted how we define, identify and estimate the occurrence of fibromyalgia in the population (Perrot, S., Dickenson, AH., and Robert Bennett n.d.). Epidemiological studies in fibromyalgia are becoming more common; however, there are significant concerns surrounding diverse study populations, methodological approaches and the operationalization of outcome measures. Thus the epidemiology for fibromyalgia remains unclear in the literature. In some geographical regions across the globe, it is difficult to understand the scope of chronic pain conditions, including fibromyalgia because of differences among cultural norms surrounding chronic pain (Mease, P. 2005)(Bernard Bannwarth et al. 2009)(Mäkelä 1999).
Estimates are that fibromyalgia affects between 2% and 5% of the US, Canadian and UK populations, which in the US accounts for approximately 6% of patients attending general practice. Similarly, estimates of fibromyalgia are approximately 3% across Western European countries (France, Germany, Italy, Portugal and Spain). Overall, global estimates range from .05 to 5.0% of the general population, with very low estimates for China, Finland and Denmark (Branco et al. 2009).  Fibromyalgia is most often diagnosed using the American College of Rheumatology (ACR) criteria (See Appendix F: Schematic ACR Trigger Points Fibromyalgia and Appendix G: ACR Classification of Fibromyalgia). Furthermore, women are between 3 and 9 times more often diagnosed with fibromyalgia than men with a ratio of 9:1 more females than males.  The age range of diagnosis is between 20 and 50 years of age. A substantial number of those diagnosed are 2 to 7 times more likely to have a co-morbid condition such as depression, chronic fatigue syndrome, irritable bowel syndrome and/or anxiety (Marcus 2009) (Weir, Peter T., Harlan, Gregory A., Nkoy, F. et al 2006). Despite fibromyalgia commonly occurring in young to middle age women, it is also observed in older adults, children including both young and adolescents along with cases among males albeit much less frequently (Chakrabarty and Zoorob 2007).

4.2.4   Symptomology

The symptoms of fibromyalgia commonly vary in intensity throughout the day and are influenced by numerous factors such as weather, stress, level of exertion, exercise and various other environmental and personal characteristics. In terms of managing symptoms, they are often aggravated by unrelated illness. Additionally, symptoms can occur continuously or in stages over time. Many people with fibromyalgia experience symptoms that prevent them from performing normal activities such as driving a car or walking up stairs. The most frequently occurring symptom shared by an overwhelming majority of individuals with fibromyalgia is widespread body pain. Patients often describe the pain as an aching, stinging or burning. The discomfort is common in many areas of the body including the neck, jaw, back, chest and legs. Pain may be found in both the joints and nerves, specifically referred to as musculoskeletal and neuropathic pain respectively. For some patients, pain is also reported as localized. Widespread musculoskeletal pain, stiffness, fatigue, non-restorative sleep, cognitive dysfunction and diminished physical function are all recurring complaints. (Baldursdottir, S. 2008). It is not uncommon for fibromyalgia patients to experience muscle tension and spasms along with, allodynia and hyperalgesia (see page 13 of this report for definitions). Individuals with fibromyalgia commonly state they have pervasive tenderness. Patients report abnormal soreness and tenderness throughout their body including thigh area, buttocks, elbows and knees along with the upper back, neck and shoulder areas. Additionally, patients also suffer from stiffness, which is common first thing in the morning and stiffness often improves but returns again upon arising after periods of inactivity (Arnold, Lesley M. 2000).

Many patients experience chronic sleep disturbances where their inability to gain deep sleep; therefore, sleep is impaired (Perrot, S., Dickenson, AH., and Robert Bennett n.d.). This is particularly important among individuals, who suffer with fibromyalgia as it is precisely during deep sleep or stage 4 where muscles recover and the body restores itself. Patients describe difficulty going to sleep, staying asleep or feeling rested upon waking (Bernard Bannwarth et al. 2009). Both physically and psychologically, scientists demonstrate that physiological aspects of the nervous, cardiovascular and immune systems along with metabolic function all require proper sleep. Restorative sleep is necessary for cognitive processing, physical endurance and for proper healing of the physical body. There are two types of sleep, Rapid Eye Movement (REM) associated with psychological rest and recover and Non-Rapid Eye Movement (NREM), which is comprised of stages. Importantly, the delta or a deep stage 4 is crucial for physical recovery of the body.  During stages of sleep, there is an increase in hormone releasing activity. The majority of individuals with fibromyalgia report poor sleep. As such levels of necessary hormones were found in lower amounts compared to their healthy counterparts (Millea and Holloway 2000). During the delta sleep stage, the growth hormone somatomedin C is released and is responsible for restoration of muscles. All adults have micro-trauma to their muscles from moving around during the day. Muscle is normally restored with the help of somatomedin C released in the proper amounts. Studies performed using sleep electroencephalograms show that up to 90% of the individuals studied, who had fibromyalgia do not enter NREM sleep stages. Additionally, other research verifies that once an individual’s sleep quality improves there is a decrease in the amount of pain and fatigue (Perrot, Dickenson, and Bennett 2008).

Numerous fibromyalgia patients report cognitive difficulties also referred to as ‘brain fog’ that is described as difficulty thinking, concentrating or problems with short term memory tasks. Brain fog is substantiated by abnormally slow brain wave patterns among individuals with fibromyalgia and commonly reported cognitive deficits. Many experts feel that ’brain fog’ is directly related to the sleep disturbances experienced by those with fibromyalgia. Finally, some individuals also experience perceptual disturbances such as difficulty surrounding the ability to make figure/ground distinctions, loss of depth perception and an inability to focus vision and attention (Glabus, Simpson, and Patterson 2009). A number of neurological symptoms are associated with fibromyalgia such as poor balance, weakness, tingling, short-term memory impairment, confusion, directional disorientation and sensitivities. A number of patients state they experience sensitivity to particular stimuli such as temperature changes, humidity levels, medications or even certain foods or smells. Such sensitivity may cause a flare up in symptoms of fibromyalgia or a more general feeling of un-wellness. Furthermore, a feeling of swelling, numbness and/or tingling is common in the face, arms, hands, legs and feet.

Patients with chronic pain conditions including fibromyalgia often report psychological distress and mood disorders. Often patients suffer from depression and/or anxiety, night sweats, panic attacks and unaccountable irritability. Depression is found more often among people who also have conditions involving soft tissue damage without having typical articular disease e.g., rheumatoid arthritis. Thus, depression and anxiety is common but not absolute in patients with chronic pain syndromes such as fibromyalgia (Nampiaparampil and Shmerling 2004). Along with psychological distress there exists severe physical fatigue. Fibromyalgia is characteristic of mild to severe fatigue and in many instances, patients with fibromyalgia also fit the diagnostic criteria for chronic fatigue syndrome.

Researchers have found that people with fibromyalgia either tend to run at a slightly higher than normal level of stress or may take a longer time to recover in stressful responses. Reacting and recovering from the human stress response involves the specific part of the central nervous system known as the autonomic nervous system (ANS) (Martinez-Lavin, M. 2007) . The ANS regulates heart rate, breathing, blood pressure and digestion, well known for the ‘flight or fight’ reaction. During the stress response adrenaline and cortisol neurochemicals cause increased heart rate, fast and shallow breathing, increased thermoregulation and decreased gastrointestinal reactions to name a few. Both acute onset and chronic stress influence how pain signals are processed in the brain which can lead to increased sensitivity mediating symptoms of fibromyalgia. Finally, other symptoms include: headaches, dermatological conditions, myoclonic twitches, irritable bowels, bladder irritation, pelvic pain, hypoglycermia, bruxism (teeth grinding), menstrual difficulties, loss of libido and impotence.  Overall, the symptoms of fibromyalgia are complex and most frequently, patients do not experience all of the symptoms associated with the disorder.

4.2.5   Triggers

It is paramount to remember that in trying to understand the presentation and etiology of disease concerning fibromyalgia that to date, no specific pathology has been identified that explains individual patient symptoms. Notably, patients consistently report pain and typically show a variety of other symptoms. Laboratory tests and other diagnostic imaging investigations are regularly unsuccessful in demonstrating specific abnormalities.

Given the cause(s) of fibromyalgia simply elude researchers and clinicians, for clarity in this report, the term triggers is used to denote an event, which when it takes place an individual then develops fibromyalgia. Given there is no empirical, thus conclusive evidence of the cause(s) of fibromyalgia, the discussion focuses on the unfolding of events from a trigger through to the development of fibromyalgia without any assumption to the causal factors of this syndrome. fibromyalgia is a complex culmination of various symptoms and is often precipitated by a trauma, which can be physical, psychological or emotional. Additionally, a trigger can also be an illness such as a viral infection. Research to date has demonstrated that there is no strong correlation between any specific event or illness and the development of fibromyalgia. However, recent developments in research and diagnostic processes have led to some understanding of the role of central nervous system (CNS) and the development of fibromyalgia. Recently, research has focused on examining various neuroendocrine, autonomic nervous system and brain activity processes, which is beginning to show neurochemical abnormalities in patients with fibromyalgia (Wood, Patrick 2008).

External factors are currently viewed as possible triggers albeit there is little understanding of exactly how or why a trigger results in the onset of fibromyalgia. The question is why do some triggers result in the development of fibromyalgia in some people and not in others?  It is unclear if characteristics create a predisposition to the condition whereby a trigger results in the manifestation of the syndrome. A major risk factor for developing fibromyalgia is having another relative in the family who has the condition. The clinical observation of familial history of fibromyalgia suggests there may be a certain genetic component responsible for fibromyalgia. Specifically, there is evidence that polymorphisms of genes in the serotoninergic, dopaminergic and catecholaminergic systems may be involved (Buskila, D., and Piercarlo Sarzi-Puttini 206). However, we do not understand what ‘turns on or off’ particular genetic influences.

In the fall of 2009, the Whittemore Peterson Institute, who are focused on neuro-immune diseases reported higher than normal levels of retroviral infection XMRV in blood samples from individuals who had a diagnosis of chronic fatigue syndrome. It is well known how virus infections play a role in inflammatory diseases and specifically the XMRV has nearly exclusively been studied in prostate cancer.  This work may prove significant in advancing the understanding of how a virus may either trigger or cause a chronic pain syndrome such as fibromyalgia or CFS (Lombardi et al. 2009). However, the research is in the early stages and importantly such results need to be replicated in much larger study populations and among diverse groups. In addition, there are issues surrounding the accuracy of diagnoses in both fibromyalgia and CFS especially as many patients with CFS also meet the diagnostic criteria for fibromyalgia and vice versa. The potential for misdiagnosis among fibromyalgia can be quite prevalent and in this particular piece of research considering the latent impact of confounding misdiagnosis must be addressed in future studies.

Wallace and Clauw (2005) provide a hypothetical model of the components leading up to the onset of fibromyalgia. An individual often has a predisposition, which in the case of fibromyalgia can be a deficiency in a biogenic amine (e.g., norepinephrine, histamine or serotonin) or a defective protein. An individual then experiences an event (trigger) such as a physical trauma or an illness that produces a neurochemical change in the central nervous system (Wallace and Daniel J Clauw 2005). The central nervous system has a role in causing a sensitization to external stimuli and the resulting central pain processing that takes place. There are a number of neurotransmitter and neuropeptide differences found within the cerebrospinal fluids of individuals with fibromyalgia (Valença et al. 2009) (See Appendix H: Neurochemicals). Furthermore, it is well documented that patients with fibromyalgia can feel pain in the body in a more extreme way, hyperalgesia compared to individuals without fibromyalgia. Hypotheses suggest that there is a different process in the way in which the body of a fibromyalgia patient actually processes pain compared to otherwise healthy individuals. Additionally, pain may be experienced by individuals with fibromyalgia from an external stimulus that would not cause pain under normal circumstances, allodynia (Mease, P. 2005). In clinical terms, changes such as aberrant pain processing, an inhibitory process in pain pathways and the alteration of neurotransmitters all take place within the central nervous systems and are thought to be related to the development of fibromyalgia (Podolecki, T., Podolecki, A., Hrycek, A. 2009)(Aryeh, M., Pillinger, Micheal H., Solitar, Bruce M. and Micha Abeles 2007)(Krypel, Linda L. 2009).

Research into diagnostic imagery and chronic pain has focused on the augmentation of the central pain processing system in the CNS. For example, in Germany a neuroimaging study showed that a structural change in the pain systems is a precondition for the central pain sensitization of fibromyalgia (Burgmer et al. 2009). Other research suggests differences in pain processing in individuals with fibromyalgia compared to healthy controls included the difference in opioid receptors, elevated levels of substance P in the cerebrospinal fluid and a difference in the activation of areas in the brain responsible for pain processing. Such results are important as opioid receptors are responsible for binding with opiates that are painkillers contained in many pharmacological agents used to treat pain. Importantly, having a reduced amount of opiate receptors (as a result from upregulation disturbances) in the central nervous system assists in understanding why individuals with fibromyalgia may have difficulty getting pain relief from standard pharmacological agents for treatment in chronic pain.

Substance P, which is three times beyond normal levels in patients with fibromyalgia, mediates pain threshold, thus determines when a stimuli will become painful. Substance P provides a possible explanation as to why individuals with fibromyalgia have such sensitivity to external stimuli, along with very low pain tolerance or feel pain in situations that would not normally produce a pain response in otherwise healthy individuals. Brain activity research shows increased blood flow to particular areas of the brain among fibromyalgia patients and also demonstrates brain activity is higher in areas that deal specifically with pain. Pain signals are significantly increased, which may result in an abnormal process surrounding an abundance of pain messages in the CNS.

Three other neurochemicals are being investigated for the role in fibromyalgia, serotonin, dopamine and cortisol, which are found in abnormally low levels in fibromyalgia patients or are not used effectively in the brain compared to healthy counterparts. These hormones each play an important part in controlling many of the processes in the body. Serotonin, which is found in lower levels, is vital to a person’s mood, sleep and pain response whereas dopamine, which researchers speculate is not used efficiently in fibromyalgia patients is thought to affect pain processing and cortisol, found in lower than normal levels may result from an alteration in the pituitary-adrenal area of the body (Millea and Holloway 2000). Other research has examined the effect of low dopamine and found that the density of gray matter in the brain was augmented (Glabus et al. 2009).

The culmination of a traumatic event and subsequent stress responses can create the environment for the onset of fibromyalgia. Once fibromyalgia has occurred in the body, the hallmark is then a change or augmentation of the central pain process in the central nervous system (Albin, JN., Neumann, L., and Dan Buskila 2008)(Dadabhoy, D., and Daniel J. Clauw 2006).  Additionally, both the development and symptoms of fibromyalgia are overlapping with other diseases for example, Lyme disease and particular triggers such as vaccinations. It is not yet fully understood how infections or other conditions act as triggers for the development of fibromyalgia, but is it becoming clearer that such occurrences are significantly contributing to the onset of fibromyalgia (Albin, JN., Shoenfeld, Y., Bushila, D. 2006).  (Albin, JN., Shoenfeld, Y., Bushila, D. 2006)

4.2.6   Burden of Illness

Overall, fibromyalgia is a challenging chronic pain syndrome that is difficult to manage and has significant impact across many areas of an individual’s life. Research comparing the overall health measures such as general health, social functioning and emotional problems found that individuals with fibromyalgia, by comparison to both the general population and those with other specific pain conditions, were significantly more impaired across 8 health status areas (Hoffman, DL. and EM. Dukes 2008). Furthermore, a study inclusive of several countries, specifically designed to assess the burden of disease associated with fibromyalgia found significant economic impact to individuals. At least half of the patients surveyed had lost work time in the past year due to their condition, while 20% reported they were unable to work and 40% of patients reported they had spent ‘substantial’ money on out-of-pocket expenses for medical services related to fibromyalgia. Beyond the physical health challenges, the economic burden associated with fibromyalgia can negatively impact access to optimal care and increase personal stress all adding to the burden of illness (Borigini 2009).

4.2.7   Diagnosis

As with other chronic pain disorders, diagnosis of fibromyalgia is established by the physician on the basis of the patient history, clinical observations and the physical exam. Importantly, fibromyalgia is a syndrome with a number of presenting symptoms that exist on a continuum; therefore, it is not uncommon for a clinician to require patient observation over time in order to firmly establish a proper diagnosis. Fibromyalgia should be considered in any patient with widespread pain that is unexplained by a clear anatomical pathology. Specific to fibromyalgia is that the diagnosis depends on findings from the history and physical examination rather than on diagnostic testing. The criteria for classifying patients with fibromyalgia were established in 1990 but do not absolutely exclude patients who do not meet the criteria (Millea and Holloway 2000). A patient’s history is important given our understanding of possible triggers such as a trauma along with the impact of stress, medical illness, sleep disturbances or abnormalities, depression and anxiety. Furthermore, the tendency of fibromyalgia to run in families along with the increased likelihood of fibromyalgia and high prevalence of the presence of co-morbid conditions are all indicative of the necessity of a full and thorough patient history (Chakrabarty and Zoorob 2007).

Despite having no specific test or diagnostic procedure to definitively conclude an individual has fibromyalgia, the physical exam allows a clinician to conclude confidently that the patient exhibits significant signs of the syndrome. The physical exam consists of applying pressure to certain places on the body to detect the level of pain or tenderness. The American College of Rheumatology (ACR) has selected 18 sites used as indicators for specific association with fibromyalgia (See Appendix F and Appendix G). The classification of fibromyalgia requires that there must be tenderness on palpation at 11 of the 18 sites, a history of pain and other clinical manifestations for a minimum of 3 months and clinicians must look for widespread pain inclusive of both the upper and lower body along with pain on both sides or bilateral body pain. Skill in palpation of tender points is critical to establishing a diagnosis of fibromyalgia. Physical findings to consider during the physical exam are the soft tissues include tender points, changes in skin texture, increased resting muscle tension and changes in the texture of the subcutaneous tissue.

Some individuals with fibromyalgia will not meet this classification and tender points may change location and intensity of tenderness or pain levels over time. Importantly, all indications of pain and tenderness must be in the absence of inflammatory processes such as redness, swelling or heat in the joints and soft tissues of the body (Millea and Holloway 2000). Importantly, patients who do not meet the ACR criteria require a complete workup including laboratory tests to ensure accurate diagnosis as presenting symptoms can overlap with other conditions so it is paramount to rule out other conditions.

3.3.8   Co-Morbid/Co-Occurring Conditions

Misdiagnosis is always a pertinent point to remember in the area of fibromyalgia as there is no gold standard, thus ruling out other joint and muscle pathologies requires vigilance on the part of the clinician to make an accurate diagnosis (Perot 2008) (Nampiaparampil and Shmerling 2004). Myofascial pain syndrome, chronic fatigue syndrome, hypothyroidism and other less commonly occurring rheumatic disorders may either be present with fibromyalgia or responsible for presenting symptoms (Chakrabarty and Zoorob 2007). An individual’s presenting symptoms are characteristic of many other co-morbid conditions and are reported in a highly subjective manner, which in some instances makes it substantially difficult to differentiate between fibromyalgia and is a particular challenge to providing an accurate diagnosis.

A barrier to accurate diagnosing of fibromyalgia is the number of symptoms than can mimic other diseases. For example, individuals with iron deficiency exhibit pain, muscular aches and checking serum ferritin levels will differentiate from fibromyalgia, when serum iron levels increase general pain improves. Additionally, people with low Vitamin D levels (hypovitaminosis D) will also experience widespread pain. Again this is addressed through Vitamin D supplementation and addressing any absorption issues, which once completed will improve pain levels.

Furthermore, there numerous other chronic syndromes that may co-exist with fibromyalgia syndrome.

• Chronic fatigue syndrome
• Depression
• Endometriosis
• Headaches
• Irritable bowel syndrome (IBS)
• Lupus
• Osteoarthritis
• Post-traumatic stress disorder
• Restless legs syndrome
• Rheumatoid arthritis
• TMJ

Chronic Fatigue Syndrome

The term chronic fatigue syndrome (CFS) is also used interchangeably with myalgic encephalomyelitis (ME). Researchers and clinicians either use the term interchangeably whereas others feel one syndrome is a sub-type of the other. The syndrome is characterized by extreme exhaustion of either gradual or rapid onset that has no alternative explanation and lasts for a minimum of 6 months. In other words, it cannot be attributed to physical exertion, any physical pathology or disease process and it not relieved through rest and/or sleep. Epidemiological estimates suggest the prevalence of CFS is between .2% and 2% in the general population. The most common age of onset is between 40 and 50 years; however, CFS has been noted in both children and teenagers. Women suffer from CFS more often than men at a rate of 2 to 3 times higher (Wyller 2007) . The exact cause of CFS remains unknown; however, recent research from the Whittemore Institute, examining the role of viruses in the precipitation of CFS holds promising information of not only explaining a cause for CFS but may lead to primary prevention protocols; however it is important to note that it is not yet empirically proven that XMRV causes CFS. The challenge for physicians is that many patients who meet the diagnostic criteria of CFS also meet the criteria set for fibromyalgia and vice versa. There is no diagnostic tool to differentiate the two syndromes. To further complicate matters, CFS symptoms also overlap with Lyme disease, infectious mononucleosis, hypothyroidism and Epstein - Barr virus (EBV).

At this time, there are no known diagnostics tests for CFS and treatment options include focusing on modifiable lifestyle factors such as diet, exercise and stress management along with some alternative or complementary therapies such as acupuncture and massage therapy. Additionally, some pharmacological agents such as antidepressants, anti-inflammatory medication and basic analgesics have shown some benefit to patients managing their CFS symptoms and improving their quality of life (van't Leven et al. 2009).

Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) affects between 10% and 20% of the population in the United States and Europe, more often females than males along and can affect all ages (Longstreth et al. 2006). IBS is classified as a chronic disorder where individuals suffer with mild to severe abdominal pain in conjunction with problems associated with bowel function. Other symptoms include constipation, diarrhea, nausea, vomiting and bloating. The exact cause of IBS is unknown but can be initiated by emotional characteristics, a bacterial or parasitic event, certain foods and in some cases inflammatory bowel disease (Kellow et al. 2006). IBS is treated by focusing on the predominated symptom and frequently involves both pharmacological agents such as tricyclic antidepressants and psychological treatments to manage both anxiety and depression, which may exacerbate symptoms. It is important to rule of differential diagnoses such as inflammatory bowel disease or celiac disease through a combination of laboratory testing and physical examination (R Spiller et al. 2007).

Systemic Lupus Erythematosus

Lastly, systemic lupus erythematosus (SLE) can also exist with fibromyalgia. SLE is the acronym given to systemic lupus erythematosus, an autoimmune disorder which presents as a skin rash or arthritis. The most commonly occurring symptoms are extreme fatigue, rash and musculoskeletal symptoms. SLE can be triggered by an infection. There are various types of lupus and SLE is the most the form people are familiar with among this group of autoimmune disorders. SLE manifests when the body’s own immune system attacks its own healthy cells as if they were a foreign invader, producing autoantibodies of which the most common is antinuclear antibody (ANA). The long term effects of SLE include damage to major organ systems such as the kidney, heart, lungs and brain. Although it is found among all populations in the world, there is a higher prevalence in those of Asian and African descent. SLE is more common among women and frequently occurs between ages of 15 to 45. (Bertsias et al. 2008). The symptomology of SLE can vary over time with periods of remission and commonly occurring symptoms are: skin rash, fever, joint problems, fatigue (most frequently occurring), cognitive difficulties, swollen glands, chest pain, seizures and depression. Despite the definitive cause of SLE remaining unknown, it is conceived of as multi-factorial in nature; SLE tends to run in families thus, either a genetic cause or predisposition is a common hypothesis.

There is no cure for SLE; however, in recent years, earlier diagnosis, pharmacological intervention and self-management have reduced the mortality and morbidity of this disorder notwithstanding the serious complications that can arise from SLE such as cardiac disease (R. Cervera 2006). Furthermore, the diagnostic investigation must consist of ruling out other diseases such as rheumatoid arthritis, systemic sclerosis, Lyme disease along with other infectious diseases such as CMV and infectious mononucleosis to highlight a few.

Most individuals with SLE are treated by a multidisciplinary team of health care professionals made up of a family physician, nurse, rheumatologist, social worker, dermatologist, nephrologists and neurologist. Various pharmacological agents employed to relieve the symptoms of SLE and the more common approaches include: NSAID’s, antirheumatic drugs, corticosteroids and immunosuppresants. New and emerging treatments for SLE are incorporating the use of antibodies (Vigna-Perez et al. 2006).

4.3.9   Treatment

No single drug or group of pharmacologic agents has shown efficacy in treating fibromyalgia patients as a whole (Abeles, M., Solitar, B., Pillinger, MH. et al. 2008). As with many other soft tissue and rheumatological organic disorders, there is no cure for fibromyalgia, but some treatment options are available. Often individuals try many different treatment approaches from traditional allopathic treatments, complementary and alternative therapies in order to effectively manage fibromyalgia. Fibromyalgia is a syndrome that may dramatically change from one day to the next and flares up under a variety of circumstances.  Goals of treatment are to control pain, thereby improving well-being, and daily functioning (Peterson, EL. 2007). Treatment is focused on reducing pain and alleviating other non-pain symptoms using pharmacological agents, cognitive behavioural therapy, exercise, self-management strategies and education along with a variety of other treatment modalities (Carville, S.F., Arendt-Nielsen, S., Biddal, H. et al. 2008).

4.3.9.1   Pharmacological Treatment (Antidepressants, Pain Killers, Anticonvulsants, Muscle Relaxants and Sleep Modifiers)

Neurotransmitters, for example serotonin, are chemicals that carry messages to and from the brain such as pain messages. Researchers believe that serotonin is either in lower than normal amounts or is not being used properly by the body in people with fibromyalgia. It is thought that low levels of neurotransmitters may be a factor in fibromyalgia and that raising the level of neurotransmitters reduces pain by facilitating the effective use of serotonin (Arnold, Lesley M. 2000). Typically the antidepressants used in the treatment of fibromyalgia are: tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors (SSRI’s) (See Appendix I for common pharmacological treatments, which may or may not be used in conjunction with alternative therapies). The presentation and severity of an individual’s symptoms along with their tolerance to the side effects dictates which specific antidepressant medication is chosen and when to use antidepressants in order to improve sleep and overall mood along with decreasing pain. Some individuals receive traditional pain killers: paractamol, codeine, tramadol which have shown effectiveness in treating fibromyalgia. More severe pain can be treated with chronic opioid analgesic therapy (COAT) that uses a combination of narcotics with acetaminophen. This particular treatment modality is reserved for patients, who do not respond to other methods of pain management or have more severe pain. Using narcotic medication over the long-term has inherent risks such as dependency; however, for more severe pain it may be necessary. The literature surrounding effective pain management for chronic pain syndromes in general illustrates that various opioid treatments are available; however, clinicians are often hesitant to prescribe these pharmalogic agents because of possible dependency issues surrounding prescribing and follow-up patterns along with potential abuse patterns.

Anticonvulsant medication is proving effective for alleviating anxiety, depression and sleeping disturbances. Pregabalin (known as Lyrica) is an anti-seizure medicine that has been found to be effective in treating several fibromyalgia symptoms. Anticonvulsants are increasingly used to treat chronic pain such as migraines and neuropathy. Additionally, anticonvulsants can also relieve fatigue, cognitive dysfunction, irritable bowel syndrome, bladder problems, restless legs and multiple chemical sensitivity. Known side effects are earaches, dizziness and vision impairment; therefore, some people tolerate anticonvulsant medication better than others. The broad spectrum of symptoms anticonvulsants are able to treat is promising in the area of chronic pain treatment. Finally, concerning pharmacological agents, muscle relaxants directly target stiffness and spasms which also often improve sleep disturbances such as restless leg syndrome and pain. When more specific sleep disturbances require treatment, sleep modifiers such as herbal supplements or sedatives are used. As with narcotic medication for pain, sedatives for sleep problems must be used carefully as there is an inherent risk of dependency.

4.3.9.2   Non-Pharmacological Treatment: Complementary and Alternative Therapies
Complementary and alternative therapies may also relieve fibromyalgia symptoms and primary types of these therapies include but are not limited to:

• Cognitive Behaviour Therapy (CBT)
• Physical Therapy
• Occupational Therapy
• Exercise
• Massage Therapy
• Aquatic Therapy
• Other Complimentary and Alternative Therapies

A specific type of CBT, biofeedback is a series of feedback cues, both visual and auditory, used to train the mind and body to control and normalize the way pain is interpreted and is used in combination with various relaxation techniques. The goal of CBT is to ‘train’ the brain so that both the perception and processing of pain is altered in a positive way to assist the patient in pain management.  Other specific types of physical therapies are also used to treat fibromyalgia. In general, the goal of physical therapy is to maximize function, reduce impairment and limit disability in patients. Physical therapists use manipulation, stretching, posture training and functional activity. For people with chronic pain conditions and certainly fibromyalgia, it can be difficult to find the right balance between exercising enough for the benefits without over-exerting, which can cause a worsening of symptoms. A physical therapist can help establish the correct balance to an exercise program while also providing a variety of treatments such as heat or ultrasound therapy between exercise sessions that can assist patients managing their fibromyalgia symptoms.

Additionally, receiving occupational therapy helps people regain and acquire skills important to maintaining their independence. Individuals with fibromyalgia experience challenges both physically and mentally.  The widespread chronic pain and often accompanying depression can make it difficult for fibromyalgia patients to compete simple daily tasks. The occupational therapist can assist in promoting independence and daily activity improvement by examining the environment, supporting caregivers and investigate what areas of the patient’s daily life are either contributing to their healing or causing further suffering. Each occupational therapy program is customized specifically for the patient by considering elements of their medical history, scope of their syndrome and the environment the patient lives and/or works in to systematically address issues that can reduce pain and add to an overall quality of life.

An important aspect of treatment for fibromyalgia is exercise. Aerobic and strength-training activities along with other forms of exercise have been associated with significant improvements in pain, tender points and sleeping patterns in individuals with fibromyalgia. For example, Yoga is an exercise choice that assists in improving breathing techniques, increasing flexibility and reducing stress all geared toward increasing the ability to self-manage and physical abilities to reduce symptoms of fibromyalgia. Unfortunately, adherence in exercise program remains low. A recent Cochrane review in 2008 of exercise in the treatment of fibromyalgia showed that research done to date demonstrates that exercise training can include aerobics, strength training and stretching. Specifically, moderate intensity aerobic training for a minimum of 12 weeks showed some overall improvement to well-being and physical function, whereas there was no difference in pain or tender points. Whether or not exercise can improve other symptoms such as difficulty sleeping, fatigue, stiffness and depression is not well understood.

There are different types of massage therapy approaches from a relaxing massage that helps rejuvenate a person to a pressure point therapy where relief is found by applying pressure on certain locations. Massage therapy is known to lower blood pressure and help to increase endorphins, which are natural pain killers reducing the pain felt by the individual. A specific massage known as myofascial release is recommended for fibromyalgia patients, which helps in subsiding severe pain along with restoring motion. Massage also aids in detoxifying the entire system. Furthermore, massage therapy increases blood flow to tissues and is described as soothing muscles along with an ability to reduce stress. Commonly, individuals with fibromyalgia who have massage therapy for treatment of their symptoms require a lighter touch with very gentle pressure. There is insufficient research into the efficacy of massage therapy in the treatment of chronic pain, it is commonly studied in conjunction with other therapies, and thus it is difficult to assess the impact in treating fibromyalgia. Finally, aquatic therapy can prove quite beneficial to individuals with chronic pain and specifically fibromyalgia. The nature of chronic pain disorders in general makes adhering to an exercise program challenging for many people. An advantage to aquatic therapy is the buoyancy provided by the water. The buoyancy assists the patient in supporting their body weight by decreasing the amount of weight on particular joints, thereby, decreasing joint stress. It is easier and less painful to perform exercises and in some instances allowing individuals to either simply complete the exercises or exercise more frequently.

4.3.9.3   Other Complementary and Alternative Therapies

Across a variety of studies, acupuncture has shown effectiveness in decreasing tender point pain. Treatments vary from weekly to intermittent treatments over months. More vigorous research using larger study populations is required to better understand the true efficacy of acupuncture as a treatment for chronic pain and specifically fibromyalgia. Hypnosis is derived from using altered state of consciousness to provide suggestive messages. For chronic pain, messaging is directed at training the patient to alter their pain perception and better manage their chronic pain. Breathing techniques are aimed at relaxing the body and taking the mind off pain and reducing stress. Slow, steady relaxation breathing can relax tense muscles and allows a patient to create a calmer environment and is an important skill for the self-management of chronic pain. Homeopathy uses a non-toxic approach to promote physical healing. The main tenant of homeopathic medicine is the ‘law of similar’ used to create a natural healing response of the body to cause a healing response. A particular substance is given in a very dilute concentration that ultimately causes a disease symptom which then causes the body to provide a natural healing response (See Appendix J: Common Supplements for Fibromyalgia and Chronic Fatigue Syndrome, which may or may not be used in conjunction with pharmacological agents).

An important aspect of managing fibromyalgia is learning to manage stress levels. Simply managing chronic pain over time in conjunction with events over the life course contributes to overall stress level for someone with fibromyalgia. Stress can be managed with or without medication; various complementary and alternative therapies are effective in reducing stress. Therefore individuals with fibromyalgia require access and support to various programs and learning opportunities to incorporate stress management techniques into their treatment regimes. A significant area for individuals with fibromyalgia to focus on is their self-management strategies. Given there is no cure, managing the syndrome must incorporate learning to moderate activity at optimal levels, processes in handling stress effectively and dedicated to managing pain. For many having social networks and social support such as support group can provide a necessary source of information and support.

4.3.10   Conclusion to A Focus on Fibromyalgia

The symptoms of fibromyalgia tend to vary greatly therefore, it is quite common for a patient to receive treatment from a variety of several different healthcare professionals (See Appendix K for a list of multidisciplinary health care team members). A transdisciplinary health care team consisting of the family physician, nurse practitioner, rheumatologists and a neurologist is best suited for optimal care and management. For this communication among clinicians, having the patient at the ‘centre’ of the care model, an understanding of a shared care plan inclusive of the entire clinical team is paramount. The family physician is ideally suited to treat fibromyalgia because the management of this syndrome requires a longitudinal relationship, openness to various treatment modalities and an overall awareness of the interactions of the environment, the patient’s health literacy and resources available to the patient (Millea and Holloway 2000). Additionally, nurse practitioners are also in a unique position to help identify patients and provide the patient-centered, one on one care that is required to properly diagnose and manage fibromyalgia. The research and development of treatments for fibromyalgia is constantly expanding and changing. Furthermore, tremendous time and knowledge are required to properly diagnose fibromyalgia including understanding the combination of the patient history, physical examination, laboratory evaluations and ruling out other causes of symptoms often confused with fibromyalgia. The family physician and entire health care team requires on-going clinical education and access to up to date clinical information to continue to add to their understanding of symptomology and recommended treatments (Peterson, EL. 2007).

Fibromyalgia has changed in its clinical perception over time. Once thought of as purely a psychiatric progression causing symptoms to a condition comprised of muscle pathology and now is more commonly viewed as a central nervous disorder. It is imperative that fibromyalgia is diagnosed early and treated aggressively as the syndrome can result in long-term chronic health issues and disability. Unfortunately, in many instances pharmacological treatments are ineffective and/or cause significant side effects when drug therapy does work. An over-riding challenge in clinically diagnosis and evaluating effects of therapy is the multifaceted nature of the syndrome and the overlapping symptoms with other chronically painful conditions (Mease, P. 2005). Drug therapy must be multifaceted as no single drug deals with all pathologies. Combinations of drug treatment along with non-pharmacological treatment approaches show the most promising improvements (Krypel, Linda L. 2009). This is extremely problematic for a large portion of individuals suffering with chronic pain including fibromyalgia. Commonly, the burden of illness from CP impacts individuals and their families financially. We know a combination of therapies are most successful in reducing pain and managing symptoms; however, the majority of alternative and complimentary therapies are third party health services whereby, patients must pay all or part of the cost out of pocket. This significantly reduces the access to optimal treatments for many individuals.

Interventions aimed at reducing chronic symptoms for individuals with fibromyalgia must be a combination of education, psychological assistance and exercise, along with medications (Peterson, EL. 2007). There is no cure for fibromyalgia, but treatment aims to reduce symptoms and improve the quality of life. Both individuals with fibromyalgia and clinicians find the lack of standard and universally applicable successful treatments for fibromyalgia very frustrating (Perrot et al. 2008). Therefore, finding the right combination of therapies, having a supportive social network and a strong sense of self-management are necessary for individuals with fibromyalgia to decrease the overall burden of disease.

For PDF file of full report including Appendices