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Fibromyalgia, Chronic Pain, and Treatments

Fibromyalgia

According to the National Institute of Health Library of Medicine(1):

Fibromyalgia is a common syndrome in which a person has long-term pain, spread throughout the body. The pain is most often linked to fatigue, sleep problems, headaches, depression, and anxiety.

People with fibromyalgia may also have tenderness in the joints, muscles, tendons, and other soft tissues

Fibromyalgia Syndrome (FMS) is also described as(2):

chronic widespread musculoskeletal pain, stiffness, and tenderness to palpation at specific TPs.

There are 18 specific “tender points” (TPs) common to many people who have fibromyalgia.  Those tender points, along with 3 months of widespread pain, sleep issues, fatigue, as well as thinking/memory problems (“fibro fog”) are commonly used for diagnosis.(1,2)

Fibromyalgia is often experienced along with depression, anxiety, headache/migraine, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosis, and/or rheumatoid arthritis.(2)

It seems that fibromyalgia is a neurological condition, specifically in the central nervous system.  Fibromyalgia includes an increased sensitivity to pain.  So, things that would normally hurt a little bit, or not at all, tend to hurt A LOT.(3)

FMS can affect anyone, however, it’s most commonly diagnosed in women between the ages 40 – 60.  In Canada, it is thought to affect 1.1% of the population, with 6 women affected for every man.(2)

Fibromyalgia is also associated with significant disability, as the pain can lead to lowered ability to do many common daily activities.(2)

It’s unknown what causes fibromyalgia, but there seems to be a higher risk associated with genetics, early childhood trauma, and learned behaviour.(2)

Fibromyalgia is thought of as a “central nervous system hypersensitivity”, one reason is that it doesn’t seem to be consistently related to inflammation.(2)

Pain – What is it?

Pain is not just a message from injured tissues to be accepted at face value, but a complex experience that is thoroughly tuned by your brain. …the science is clear: every painful sensation is 100% Brain Made®, and there is no pain without brain. (4)

We used to think that pain was a signal from an injured tissue sent up to the brain.  We thought that that pain signal was proportional to the amount of injury.

We were wrong!

Pain is a two-way conversation between nerves and the brain.  And it is the brain that decides how much pain to perceive.(4)

Paradoxically, even though pain is strongly regulated by your CNS, it is certainly not “all in your head.” The idea has always been been disrespectful to pain patients, but now it is also scientifically obsolete and can be thrown out with yesterday’s trash.(4)

But what is the use of pain?  Why should we experience it?

Pain is a motivator. It exists to get us to act. We hurt when our brains reckon we should do something differently, for safety…but safety is not always possible. The nature of the danger isn’t always clear, or avoidable.(4)

This is shown in examples of people with “phantom limb pain”, where pain is felt in a limb that has been amputated.  This is also shown when people with serious injuries don’t feel nearly as much pain as you think they should.

My Pain Experiment

In fact, when I was in prenatal classes we had to do a pain experiment to help prepare for childbirth.  And you can do this too – all you need is a watch/timer and two ice cubes.

We had to spend as long as possible holding an ice cube in our hand.

The first time we were thinking about that ice cube.  Focusing on that ice cube. Wishing the ice cube was not freezing our palms.

I don’t think we lasted more than 30 seconds.

For the second part of the experiment we had to do the exact same thing – but this time were thinking about being in our favourite place, with our favourite people.  Focusing our attention on our lovely thoughts (of a beach, perhaps).

I was very surprised at how much longer I could hold the ice cube when I wasn’t thinking about it wishing things were different.

Focusing on it made it less bearable.

But we can’t really “think” ourselves out of experiencing pain

Most people only have a limited ability to “think” themselves out of pain.

And the brain can’t be manipulated simply by wishing, force of will, or a carefully cultivated good attitude. The brain powerfully and imperfectly controls how we experience potentially threatening stimuli, but I’m sorry to report that you do not control your brain. Consciousness and “mind” are by-products of brain function and physiological state. (Deep, eh?) It’s not your opinion of sensory signals that counts, it’s what your brain makes of them that counts — which happens quite independently of consciousness and self-awareness. This is why many wise, calm, confident optimists still have chronic pain.(4)

So it is often is with pain: if the brain believes there’s a threat, you’re going to hurt, no matter how pointless it is or how intensely you focus on trying to have more reasonable and rational sensations. It’s mostly just not up to you.(4)

So, how much influence can your mind have on your experience of pain?

Most people with chronic pain aren’t just a little stressed, they are a lot stressed, and often by major life challenges and social problems that they literally cannot solve. Even when their problems are theoretically more manageable, most people find it extremely difficult to troubleshoot their own mental health. So while it’s correct to tell patients to “learn to reduce stress” and “consider how your thoughts and emotions are affecting your nervous system,” that advice is impractical without more and better information.(4)

Fibromyalgia and Chronic Pain

While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, chronic pain is different. Chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years.(5)

Chronic pain is experienced in fibromyalgia; as well as endometriosis, chronic fatigue syndrome, interstitial cystitis, irritable bowel syndrome, temporal-mandibular joint dysfunction, and more.(5)

While between 14% and 26% of the American adult population suffer from chronic pain or arthritis, about 11% complain of chronic widespread pain.(2)

Fibromyalgia’s symptoms are very similar to myofascial pain syndrome (MPS), in fact about 70% of fibromyalgia patients also have MPS(2).  One difference is that heat can help myofascial pain syndrome, while it can aggravate fibromyalgia.(3)

There seem to be several abnormal pain mechanisms associated with fibromyalgia and they lead to a problem with “volume control”.  People with fibromyalgia seem to be more sensitive to not only pain, but also heat, noise, and even strong odours.  There seems to be a “sensory amplification” known as allodynia.(2)

This makes FMS a neurosensory disorder associated with difficulties with pain processing by the central nervous system (CNS).(2)

There is a lot of research and a lot of theories as to how the spinal cord and brain process stimuli differently in people with fibromyalgia.  This is where all of the different medications come into play.

Treatments for Fibromyalgia and Chronic Pain

The main goal of treatment is to reduce the pain, but not all patients experience it the same.  Also, some people are very sensitive to certain medications, so the “low and slow” method is recommended.  Also, the use of non-drug treatments should always be considered.(2)

How best to handle fibromyalgia

The “optimal intervention” and the “most successful medical treatment” of FMS includes several approaches:

A meta-analysis of FMS treatment interventions found that the optimal intervention for FMS involved both medication management and nonpharmacological treatments (especially exercise and cognitive behavioral therapy) to help sleep and reduce pain symptoms.(2)

The most successful medical treatment of FMS is an interdisciplinary approach that coordinates care from a physician, a nurse, a physical therapist, a psychotherapist, a relaxation therapist(biofeedback), and as needed, an occupational therapist.(2)

Medications

There is no “gold standard” for medications for fibromyalgia.  Many medications are prescribed for pain control, but very few are actually approved specifically for fibromyalgia (in Canada and the US):

• Cymbalta/Duloxetine (analgesic/antidepressant/antianxiety)
• Lyrica/Pregabalin (analgesic)
• Milnacepran (antidepressant) is approved in the US, but not in Canada

Medications used for pain are often analgesics such as acetaminophen and NSAIDs.

Also, some anti-depressants can help with pain, as well as sleep and fatigue because of their effect on serotonin and norepinephrine (i.e. SNRIs – Serotonin Norepinephrine Reuptake Inhibitors).(6)

Serotonin is involved in moderating pain, sleep, depression, and hypothalamic hormone release. The majority of the various types of antidepressant medications deal, at least partially, with serotonin reuptake.(2)

When 26 studies evaluated antidepressants in FM by meta-analysis, 13 for amitriptyline, 12 for SSRIs (5 paroxetine, 4 fluoxetine, 2 citalopram, 1 sertraline), and 3 for SNRIs (2 duloxetine, 1 milnacipran), all agents with the exception of citalopram, showed a positive effect on pain, fatigue, depression, sleep and quality of life.(6)

Some anticonvulsants (e.g. gabapentin & pregabalin) have also been shown to help with pain.(6)

Opioids such as Tramadol are sometimes used, and if so, should be used with caution and regular monitoring.(6)

There are others as well.  Definitely speak with your doctor and maybe consider referring them to reference (2) Disease-a-Month – Fibromyalgia and/or reference (6) 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome.

Sometimes the medications work better when strategically combined with each other, as opposed to taking just one.(2)

And don’t forget that, in addition to the medications, there is evidence that education, exercise and/or psychological interventions (such as cognitive behavioural therapy) can help.(6)

Special Note from Leesa –

If you are taking medications, please know which supplements they are known to interact with.  Make sure your prescribing doctor and/or the pharmacist know any complementary and alternative approaches you are using.

Complementary and Alternative Medicine

Other treatments, including complementary and alternative medicine, have had inconsistent results when studied.(6)

There is some evidence that tai chi and qi gong have been shown to help.  So have two types of massage therapy “manual lymph drainage” and “connective tissue massage”.(7)

People use other approaches as well.

A study from the Mayo clinic found, via a survey of 289 patients, that the 10 most common complementary and alternative medical therapies included exercise, spiritual healing (prayers), massage therapy, chiropractic therapy, vitamin C, vitamin E, magnesium, vitamin B complex, green tea, and weight-loss programs.(2)

Marijuana and Cannabis

Stay tuned next week where I’ll be sharing some of the recent research findings on marijuana and cannabinoids

References:

(1)  NIH Library of Medicine – Fibromyalgia

(2)  Disease-a-Month – Fibromyalgia

(3)  Pain Science – Trigger Points and Myofascial Pain Syndrome

(4)  Pain Science – Pain is weird

(5)   NIH National Institute of Neurological Disorders and Stroke – Chronic Pain Information Page

(6)  2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome

(7) NIH National Centre for Complementary and Integrative Health – Fibromyalgia: In Depth