FIBROMYALGIA could be described as the step-sister of chronic fatigue syndrome. For the most part, neither entity is a particularly acknowledged or, indeed, understood guest at the table of day-to-day clinical practice. Fibromyalgia is a condition on the periphery of the professional consciousness, but one which is central to the constant bewilderment and frustration of its encumbents.

Fibromyalgia is a real pain. On a simple level, it may be classified as a painful rheumatological condition of at least six months duration, characterized by muscle and soft tissue tenderness. It is usually associated with chronic sleep disturbance and extreme fatigue. While agreement on the number of sensitive points vary according to the different colleges, 11 out of 18 points seem to be largely acceptable.

A significant landmark in documenting Fibromyalgia was the Copenhagen Declaration of 1992, which not only endorsed the 18 tender points, but officially acknowledged many of the other commonly associated with Fibromyalgia.

In respect of this pattern, here is a summary of related symptoms:

• Musculoskeletal: Joint stiffness/pain. Restless legs/'heavy' legs. Subjective swelling of the extremities;
• Gastrointestinal: Bloating/bowel disturbance. Indigestion. Food intolerance/allergies. Crampy abdominal pain;
• Urogynaecological: PMT. Dysmenorrhoea. Frequency/nocturia;
• Neurological: Headache/poor memory. Dizziness. Poor concentration;
• Psychological: low mood/mood swings. Anxiety;
• Dental: TMJ dysfunction;
• Immune: Recurrent infection.

In our world of specialization and departmental demarcation, such a broad pattern may easily be missed. Many of these patients will have visited gastroenterologists, gynaecologists, dentists, etc. before finally being diagnosed. It is essential, then, to stand back and see the big pattern.

Patients who present such a list either exhaust our reserves or, alternatively, give an incomplete picture, as very many report they are 'too embarrassed' to keep on rolling out the symptoms for fear of being branded a hypochondriac.

These are also a group of people (80-90% women) who tend to look well despite their ailments and who regularly push themselves relentlessly despite their tiredness. Eventually many succumb to the strain and cease to work.

The final major problem (apart from a low professional index of suspicion, little reference to it in post-graduate/undergraduate training and the lack of a clear therapeutic pathway to follow) is the perplexing negative returns on the standard battery of tests. So its gallic shrugs all round!

Obviously, this then begs the question: if all the tests are negative, is Fibromyalgia a type of psychosomatic disorder? Apparently not. For, in common with many therapeutically resistant problems, there appears to be a swarm of subtle colliding issues initiating and perpetuating this problem.

A frequently observed trigger factor is a sudden shock to the system, such as a car accident or complicated surgery. Gradually altered sleep patterns may ensue.

Chronic interruption of deep sleep periods with bouts of waking type alpha waves result in poor overall sleep quality. It has been shown that prolonged selective non-REM sleep deprivation may induce Fibromyalgia type symptoms in normal subjects over time.

The issue of sleep disruption is of immense importance with respect to Fibromyalgia. In 1998, the journal of Clinical Endocrinology found that melatonin secretion was decreased by 31% in these patients. Certainly, it is no surprise that melatonin is decreased since its precursors, tryptophan and serotonin tend to be low. However, melatonin can also be reduced by emotional and electromagnetic stress, among other reasons.

What are the consequences of poor melatonin output? Firstly, melatonin is implicated with inducing deep sleep which we know is associated with tissue repair. Secondly, it has been found that melatonin indirectly activates interleukin 4, leading to activation of natural killer cells and phagocytes, etc. the Journal of Hormonal and Metabolic research (1997) found that important antioxidant enzymes are stimulated by melatonin. A general reduction, therefore, may induce reduced tolerance of inflammation, oxidative damage and immune suppression, etc.

Low serum serotonin levels (or deficiencies of precursors) and numerous abnormalities of the neuro endocrine axis are implicated. A study in 1994, using SPECT technology, assessed cerebral blood flow patterns of Fibromyalgia sufferers. It was noted that there was a decreased blood flow in respect of the caudate nuclei, which are involved in pain regulation (as well as memory and concentration). It has also been found that there are three times normal the level of substance P in the spinal fluid. It's not surprising then that the pain may be felt excessively.

That bizarre pattern of skin hypersensitivity from which these patients suffer could easily be written off as hysteria. However, research has detected real physiological anomalies. It has been found, for instance, that there is a pattern of vasoconstriction occurring in the skin above trigger points, inducing localized tissue hypoxia and, therefore, poor tissue metabolism and extreme tenderness.

Excessive deposition of fibrin or contractile tissue bands, binds muscle tissue, thus causing localized ischaemia. On a microscopic level, this can be widespread, as in Fibromyalgia; or highly localized and distinct, as in Myofascial Pain Syndrome. These problems may coexist - and frequently do.

A variety of papers have implicated viral infection, though some researchers point the finger more intensely at fungal by-products for disrupting cell energy production in muscles. Added to this is a litany of possible deficiencies of minerals, amino acids and enzymes. It is not a pretty picture. Indeed, it is a very complex one.

And the picture becomes even less appealing if one were to consider yet more of the symptomatic variables which have not been included. Many patients present (on extended questioning) with an inordinate number of symptoms and complaints covering almost every organ system. As unlikely as it seems, their symptoms are, for the most part, genuine.

As these patients tend to have a veritable kaleidoscope of problems, the query arises as to how, at a fundamental level, is this clinical situation to be tackled?

Certainly night sedation, injections in trigger points and occasional analgesics may be of benefit (in conjunction with adequate rest and graded exercise and physiotherapy). However, unless a composite, multi-dynamic approach is taken, these people will be subjected to years of poor quality living.

The ability to integrate body systems and make connections between seemingly diverse facets is of considerable fundamental importance. It is also necessary to identify causal chains and disconnect them as soon as possible. To do this, however, one must correct without causing further imbalance. That requires treatment from a biological perspective - or at least a perspective that is aligned with the body's natural dynamics.

If that approach is adopted, the results could surprise you.

Key Points:

1. Muscle pain + sleep disturbance + fatigue - check points;
2. Their problems are genuine;
3. The longer it is left, the more difficult it is to treat (author's experience);
4. Patient self-help groups: Cork 021-432-0201; Kerry 086-160-7355.

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