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more frequently in males, especially combat veterans. The current medical explanation for the pathophysiology of fibromyalgia is incomplete. Anyone who has seen a television advertisement for a fibromyalgia drug has heard that the condition is caused by "overactivity of pain- sensing nerves." Studies on fibromyalgia do show that the brain and spinal cord in these patients increase the volume of pain signals, resulting in pain hypersensitivity. 4 In fact, pain-processing problems are only the tip of the iceberg. Pain hypersensitivity is the result of a chain reaction started by a malfunction of the part of the brain that regulates the autonomic nervous system. In fibromyalgia, the hypothalamus continually activates the fight-or-flight nervous system, like a malfunctioning smoke alarm that sounds constantly, even when there is no smoke. Several studies, using different methods of assessing the autonomic nervous system, describe a relentless hyperactivity of the sympathetic nervous system. The findings led one group to conclude that "fibromyalgia may represent a primary disorder of the stress system." 5 As part of the fight-or-flight activation by the sympathetic nervous system, the brain sends signals to tighten the fascia and muscles, thereby increasing their strength to fight or flee. 6 In fibromyalgia, there is no relief from this tension, to the point that a pressure-gauge needle inserted into fibromyalgia muscles shows increased pressure, compared to healthy controls. 7 When the muscles and their surrounding fascia are chronically tightened, as in fibromyalgia, they become inflamed and painful. Two muscle biopsy studies revealed excessive and disorganized collagen and increased inflammatory chemicals in the fascia of fibromyalgia subjects. 8 These are similar to changes seen in connective tissue in other painful conditions, such as plantar fasciitis and tendinitis. The fascia is rich with pain- sensing nerves, and the constant pain signals generated from the tight and inflamed fascia ultimately overwhelm the spinal cord and brain and induce a state of hyper- reactivity to pain. To understand it, imagine the tightness and pain of plantar fasciitis permeating throughout your whole body! Thus, manual therapies that reduce that tightness and painful inflammation are critical to recovery in fibromyalgia. But how do you apply manual therapy to a nervous system super-sensitized to touch—one that has all its danger and alarm signals activated—and to tight and inflamed muscles and fascia? The key here is to focus on treatments that tone down the signals of the sympathetic nervous system and reduce fascial tightness. Fascia is sometimes described as a dense gel (the ground substance) in which fibers of collagen, elastin, fibroblasts, and other cells are suspended, giving it colloidal properties. For manual therapies to be effective in fibromyalgia, they must take into account the colloidal properties of fascia. "This makes a gentle touch a fundamental requirement when attempting to produce a change in, or release of, restricted fascial structures which are all colloidal in their behavior." 9 Therefore, only slow and sustained pressure will effect changes in the fascial tissue. RESEARCH ON MASSAGE FOR FIBROMYALGIA There is an expanding body of research on various manual therapy techniques for fibromyalgia, much of which is driven by connective tissue and myofascial techniques. A recent systematic review led by S. L. Yuan assessed 10 studies on massage therapy in fibromyalgia, including Swedish massage, connective tissue massage, manual lymphatic drainage, shiatsu, and myofascial release. 10 The studies found that all styles of