What can be done about fibromyalgia pain?
Hello my friend!
In the first two blogs, I talked about what is fibromyalgia pain – that it is a neuroplastic type of pain which comes from misfiring neurons of the brain pain centers and pain pathways.
In the second blog How does fibromyalgia pain come to be?, I explained that it is believed that certain emotions, including past traumatic events, current or past stress all increase “agitation” levels of our central nervous system which in turn sends danger signals in the brain and that CAN PRODUCE PAIN in the body!
I also stressed several times that the PAIN of FIBROMYALGIA IS REAL. You feel it is real. The reason it has gotten a lot of negative “press” in the past is that women were felt to be making the pain up or that the pain was “in their heads”.
The pain is REAL and it is caused by the brain. It is NOT a product of their imagination!
Today, I will summarize my framework for approaching this problem.
So, in summary, there are THREE BASIC steps that one has to follow in order to get started on the journey of improvement from fibromyalgia pain. They are:
1. Confirm the diagnosis of Fibromyalgia.
2. Embrace the mind-body connection and the notion that the brain can cause pain.
3. Reframe the meaning of pain and create the sensation of SAFETY for your nervous system. Steps that have high chance of getting you there include:
a. Practice of self-compassion and mindfulness.
b. Somatic tracking.
c. Believe in (yourself and) your brain’s capacity to rewire the pain pathways.
Let me elaborate.
1. Confirm the diagnosis of Fibromyalgia.
It is of crucial importance to have the diagnosis confirmed by a Rheumatologist. This is not just to plug for myself or my practice. I truly believe, and there is data to support this, that Rheumatologists are uniquely trained and positioned to diagnose the condition. Why you ask?
We are trained to look for clues on your history (meaning what you tell us, what your symptoms are) and your exam, that may point to the diagnosis of an inflammatory or autoimmune process. Fibromyalgia symptoms MAY LOOK LIKE inflammatory symptoms of someone with RA or other inflammatory conditions. We, the rheumatologists, are the ones who help you distinguish that.
The reason it is important is that RA, Lupus and other inflammatory conditions get treated with medications that suppress the immune system and decrease inflammation. Fibromyalgia does not get treated with these meds. So it is of crucial importance to distinguish.
For the first visit, we generally want to see, or check ourselves, several labs including blood counts, liver, kidney, inflammation, muscle test and thyroid. Sometimes we check vitamin D level. If these are all normal and exams are normal, we don’t usually look further. In some instances, if the labs are normal but the exam is not completely normal we look further. That is why you want to see us first.
So I hope I helped explain this topic.
2. The second point was to start embracing the concept of neuroplastic pain. This is so crucially important. We as physicians are still learning how to explain this to our patients so that they have a good understanding of the scope. I still see quite a few patients whose first reaction to my explanation about neuroplastic pain is: “oh are you saying my pain is not real?”. That means that despite my best efforts to reassure the person that the pain is real, there is no damage to the tissues, the message still gets lost. It IS A LOT to take in. If you have lived with pain for years or even a decade, and you believe that there is something wrong with your body, you can feel naturally dis-inclined to believe that the body is ok and that the pain is all produced by your brain. You could ask “why would my brain do that”? So yes, I get it, it is hard to accept at first.
I usually just start by asking my patients to be OPEN to the idea of neuroplastic pain. They don’t have to believe it or accept it right away. Because you can start taking steps to feeling better even without believing it fully.
But it IS important to start being OPEN to the idea of neuroplastic pain. Acceptance changes something in our brain that allows learning and new information to settle in.
3. The last step is to be willing to do things you never tried before.
I would like to touch upon the practice of Self compassion and mindfulness daily today.
And as serendipity would have it, I had the privilege of listening to Dr. Kristin Neff speak late in 2021. Dr. Neff is the leading researcher on compassion, self-compassion and its effects on mental health. It was truly transformational for me to hear her confirm what I have suspected for so long. Mindfulness and self-compassion are crucial in healing our nervous system (and thus improving the pain).
So what does it mean, you might ask, to practice self compassion? It means CARING about the pain and suffering of others and YOUR OWN.
I mentioned in the earlier blog that stress activates our “flight or fight” response. That sends danger signals to our primitive brain and increases cortisol levels in our body. Increased cortisol levels can directly lead to pain through increasing tension in the back muscles (and other muscles in the body) or just increasing sensitivity of the neurons to pain signals.
Practicing self compassion lowers blood pressure, heart rate and INCREASES levels of oxytocin in our body. Oxytocin is the “feel good” hormone that is released when the mothers first bond with their newborns, or anytime we have somebody touch us with care and kindness.
A practice of self compassion does not have to be complicated. It has three main components (kindness, awareness and the sense of common humanity) and literally means the following steps:
- Find a comfortable position, close your eyes.
- Slow down your breathing.
- Bring your attention to something stressful happening in your life.
- ACKNOWLEDGE the pain or suffering you are feeling. Name it – it could be anxiety, sadness, frustration. FEEL THE EMOTION.
- Now imagine what you would say to a good friend if they were in this situation – it could be something like: of course you are sad or frustrated. Or angry. This is the human experience. It happens. Life is not perfect. Mistakes happen. Life happens. This is the human experience. You did or are doing the best you can. This is all you can do.
- And NOW SAY IT TO YOURSELF.
- Feel the emotion, allow yourself to feel it.
- Put a hand over your chest as if putting it over the heart to protect it, and feel kindness to yourself as if it was your friend or someone you love, because - it is. You are your best friend.
- Believe this friend that this is part of human experience, other people suffer too. You are not alone.
- You don’t have to fix it, you don’t have to do anything else, you are just bringing awareness to the emotions you are feeling, and you say kind things to yourself, because you care.
- That’s it, you can open your eyes.
Self compassion is not sugar coating things. It is also NOT letting yourself off the hook. It is OPENING YOURSELF TO PAIN WITH KINDNESS. If you made a mistake, and you feel guilty, with kindness you can commit to doing your best not making the same mistake again. Rather than feeling shame you feel resolved not to make the mistake again.
When your brain gets kindness in response to frustration, anger, anxiety, something changes in the way you are able to deal with stress and pain. Your chemistry changes.
Everyone has THEIR OWN flavor of suffering. I have rheumatoid arthritis and some chronic aching in my back, another person has back pain, and yet another person has a history of significant trauma. Everyone has some flavor of pain and the amount is different and the way it manifests is different. THE HUMAN EXPERIENCE is about CHALLENGES. That’s what it means to be HUMAN. There is not a single person alive who does not have some pain or difficulty.
When we remember that truth, what happens is that instead of feeling all alone in our suffering and isolated in our struggles, we feel more connected to other people. The sense of CONNECTEDNESS gives us a sense of strength and coping and feeling we can handle this because this is a human condition.
So the main three components of self compassion are mindfulness/awareness of our pain, kind warm response to the pain and remembering that everyone has struggles. I am going to leave you with that thought.
How does fibromyalgia pain come to be?
Hello again my friend!
Welcome to the 2nd blog of the Whole Health Rheumatology of Cape Cod blog. I am Dr. Martina Ziegenbein, a rheumatologist and the owner. Today’s blog title is: How does fibromyalgia pain come to be?
In the first blog yesterday, I explained the difference between acute and chronic pain, with the biggest contrast being that the former comes from the neurons in the injured tissues and the latter, also referred to as NEUROPLASTIC pain, comes from misfiring neurons in the brain.
Here is the kicker: BOTH pains are processed in and by the brain. In the case of neuroplastic pain, the brain changes in a way that reinforces chronic pain. The neurons in the brain are misinterpreting safe (or neutral) signals from the body as if they were dangerous.
BOTH PAINS feel the same AND ARE REAL. I feel It is important to stress this again. The PAIN of fibromyalgia, and any chronic pain for that matter, IS REAL. However, based on our current knowledge, there is no damage to the tissues that are hurting in patients with fibromyalgia. So what is going on?
I will give you a short answer and then explain it: stress, emotions and especially fear.
It is common knowledge that stress can cause physical reactions. My face turns red when I am embarrassed. That’s because my emotions cause the autonomic nervous system to increase blood flow to the face. For somebody else it can be sweaty palms when they are nervous or have an upset stomach. These are not signs of disease, just normal physical reactions to stressful events and the mechanisms of BODY MIND SYNDROME. Stress causes emotions that cause our bodies to react by producing physical symptoms. The symptoms are real.
What is not common knowledge is that stress and emotions can create the neural pathways that can cause chronic and often severe physical symptoms. The cure for such chronic pain or other symptoms is not a drug but rather to identify and treat the underlying cause of the stress. For most people, the underlying cause is that the emotional reactions to stress trigger neural circuits that create physical pain.
During times of stress, the emotion-based network sends signals to activate the autonomic nervous system (ANS) and produce hormones of cortisol and adrenaline which turn on the “fight or flight” reaction. That’s a system that directs blood flow to muscles to get our body ready to run or do battle, and it causes our bodies to react instantly before we are aware of what is going on. We have this system to protect us from danger and improve our chances of survival. When we see a squiggly thing that looks like a snake on the ground as we walk in the woods, we jump back, we don’t investigate what it might be.
The autonomic nervous system controls the nerve fibers that affect every area of our body. Studies have shown that emotions such as anxiety or anger cause increased tension in the back muscles of people with chronic back pain. This muscle tension, which can occur WITHOUT our conscious awareness, can cause severe and real physical pain. Often we are not aware of the emotions that are triggering these automatic physical responses.
The autonomic nervous system can produce a large variety of physical symptoms in humans in response to stress and emotions. They include: tingling, numbness, burning sensation, dizziness, tinnitus, anxiety, abdominal pain, heartburn, diarrhea, constipation, pain, itching…you get the idea, the list goes on.
The brain has complex mechanisms to handle pain that involves many structures. One part of this mechanism is anterior cingulate cortex (ACC). Emotional responses increase activity in this area, causing pain to be amplified. MRI studies show that when ACC is activated the pain is generally increased.
Emotional experiences in childhood are imprinted in the brain. Human infants that are exposed to repeat blood drawing within the first few weeks of life have increased pain when they have medical procedures several months later. Adults who are exposed to traumatic events in childhood such as emotional, physical or sexual abuse have a much higher chance of developing chronic pain.
Chronic stress produces increased sensitivity to pain in the brain, the spinal cord, and the nerves. Certain cytokines are released during the times of stress, and these cytokines cause cells and nerve endings to be more sensitive to pain.
At least one study showed that adults with chronically elevated cortisol levels are more likely to develop pain. This further cemented the relationship between chronic stress and chronic pain.
Our brains have trouble dealing with the chronic stresses of modern life. When stress becomes chronic and we feel trapped in situations for which there is no easy way out, we can easily develop a set of neural circuits that are painful.
Many patients I have worked with started experiencing pain shortly after or during a stressful situation in their lives. Big life changes, positive OR negative, can generate feelings of stress. With many of my other patients, it is their past experience of exposure to physical or emotional or sexual abuse, that predisposed them to chronic pain. Certain behaviors, such as worrying, self-criticism and putting pressure on ourselves can also set up stage for chronic pain by putting our nervous system in the state of high alert (or chronic flight or fight reaction).
So how does an acute injury evolve into chronic pain in the setting of stress?
It can be a sprain, fracture or strain. Most injuries heal within several weeks. After that, if the pain does not go away, something else is usually going on. Many times, patients feel that the injury never healed or that there are “misalignments” that continue to cause pain. This is not really supported by research. Even if there is scar tissue, scar tissue does not cause pain. The injury triggered a series of events that lead to the vicious CYCLE of pain.
In the setting of stressful life circumstances occurring around the same time as the injury, NERVES that carry danger signals from the site of injury to the brain are activated for a prolonged time. They become SENSITIZED, meaning they are more likely to fire and send more danger signals with lesser amounts of tissue activations.
These small nerves learn to react to even very minor changes, such as tense muscles, which are EASILY triggered by an overly active ANS (autonomic nervous system) and ACC (anterior cingulate cortex) – part of the brain that is closely connected to emotions.
These tiny nerves eventually start affecting the brain, through communications to the brain with other neurons. The areas of painful sensation in the brain also become sensitized. They continue to experience pain. Bam, this is where the scientists used the term of neuroplasticity (or brain reorganization = the brain’s ability to create NEW pain pathways).
The term BODY MIND SYNDROME is used to express the connection between the reactions/symptoms in the body and the brain. One of the best examples of Mind Body syndrome is Phantom limb syndrome – people who had their limbs amputated continue to feel pain in an extremity that is no longer attached/present. That’s because brain re-organization and nerve sensitization happened.
Going one step further, a group of researchers tried to determine whether the brain could actually CREATE pain. It is described in books by Dr. Alan Gordon in his new book WAY OUT and Dr. Schubiner’s book Unlearn Your Pain: A Study at University of Pittsburgh looked into hypnosis and pain. Researchers placed subjects in an fMRI machine and administered pain with a hot probe. The pain regions of the participants’ brains lit up. Then the scientists took the same subjects and HYPNOTIZED them, and induced pain through suggestion. The exact areas of their brains lit up on fMRIs. WHETHER THE PAIN WAS INDUCED PHYSICALLY OR THROUGH HYPNOSIS, THE SENSATION WAS THE SAME, as far as the brain was concerned.
This was the first evidence that the brain can CREATE PAIN that is indistinguishable from pain caused by stimulation of nerves in tissues! Real pain can be caused by either physical disease states OR by neuroplastic processes that create learned neural circuits. The fact is that ALL pain is experienced in the brain. We cannot have pain without activation of the pain pathways in the brain.
The pain is NOT in the HEAD, IT IS IN THE BRAIN!
Whole Health Rheumatology of Cape Cod - Our First Blog Post!
Hello friend!
I am super excited to introduce you to my first Blog of 2024 (and the first one of the Whole Health Rheumatology of Cape Cod practice evvverrrr). We opened our doors on 11/30/2023, eek!
My name is Dr. Martina Ziegenbein, I am a board-certified Rheumatologist. Rheumatology is a field of Medicine that deals with all kinds of arthritis but also autoimmune conditions like lupus, vasculitis, and myositis.
Whole Health Rheumatology of Cape Cod is currently a general Rheumatology private practice. My expertise lies in diagnosing and distinguishing inflammatory conditions from noninflammatory ones. Chronic pain is one of those non-inflammatory conditions and part of my expertise. So I will talk a lot about chronic pain here.
The reason it is so relevant to talk about it is because chronic pain is a huge issue in healthcare. One out of five people in the world and in the USA suffer from some form of chronic pain.
Over the next several days, each day I will share a small but crucial piece of the puzzle of chronic pain.
Today, the first question to be addressed is: Where do chronic pain and fibromyalgia pain come from and how is chronic pain different from acute pain?
Fibromyalgia has many definitions in literature. It can be most simply described as “pain all over'', literally. It affects more women than men and those patients often describe the pain as being present “from head to toe”. And as if the pain was not enough, it often comes along with a bunch of other symptoms including, but not limited to: brain fog, overwhelming fatigue, irritability, inability to concentrate, headaches, jaw or TMJ pain, IBS, vaginal or bladder pain (sometimes also referred to as interstitial cystitis). Many patients with fibromyalgia also describe weird tingling or burning sensations in their hands or feet.
Fatigue and pain are the most overwhelming symptoms and literally rule the life and make lives miserable for many women who are unfortunate to suffer from it.
No one is really sure what is causing it. Genetic reasons, prior trauma (whether physical, emotional, or psychological) are all suspected causes. In general, the origin of the fibromyalgia pain is NOT believed to be autoimmune.
Rheumatologists usually see a patient with fibromyalgia for the initial consultation, to confirm the diagnosis and then generally the patient is returned to the primary care doctor with recommendations on what to implement in a treatment plan. My practice is different in that I KEEP all the patients with fibromyalgia who want to keep working with me! 🙂
I have been fascinated by fibromyalgia for a long time. It has not always been “smooth” to care for these patients - the solution to pain felt too elusive and out of reach. Many times no matter what I tried for these patients, the pain would not remit or not remit consistently. After I moved from WI to Cape Cod in March 2021, I studied more materials, immersed myself in all things fibromyalgia and I was so happy to realize that the solution clearly IS AVAILABLE.
What is causing the pain? First of all – PAIN IS REAL. In the past, many women felt not believed or dismissed because the pain was referred to as “psychosomatic” which for some reason meant that it was not real. Let me tell you – the pain IS REAL. You feel the pain, it hurts – the pain is real. However, the pain is not coming from where we feel it - in the body – but rather from the brain or central nervous system! Let me explain.
When we sprain our ankle or burn our hand on the stove – the pain is referred to as acute. The pain receptors in the tissues that are injured communicate the information through neurons into the spinal cord and from the spinal cord the information goes into the brain. The brain tells us to stop doing whatever we were doing that injured us. We limp for a while, we have a burn on our hand, we heal and the pain resolves. I will refer to that pain as “plain” pain or “regular” pain. It is a survival mechanism and was meant to alert us to danger. So far so good? Acute pain leads us away from danger and promotes healing.
Fibromyalgia pain on the other hand, is chronic, happening on a daily basis and fluctuating in severity. There is nothing healing about it. Through rigorous and extensive research studying functional MRIs of the brain of patients with pain, it was discovered without any doubt that the chronic pain of fibromyalgia is basically a conglomerate of misfiring neurons. It is a mistake of the brain who is mis-interpreting regular signals from the body as “danger”. I just mentioned above that the brain interprets pain as danger and that it is a survival mechanism. We are wired to interpret pain as danger. Danger is meant to put us on high alert. High alert means augmentation of our senses which can lead to (or even create) more pain. More pain leads in turn to more danger signals – which leads to more high alert messages to the brain which leads to more pain. It is referred to as NEUROPLASTIC or BRAIN PAIN. Chronic pain – neuroplastic pain. That means the fibromyalgia pain is brain pain, it comes from the pain.
I feel it is important to stress again that the pain IS REAL. There is nothing imaginary about the pain. But the origin of the pain is basically brain centers that are full of misfiring neurons that are dealing with faulty information.
As a side note, there are cases when chronic pain is NOT neuroplastic, for example patients with cancer – these patients have chronic pain that is not neuroplastic. OR they have a combination of acute and neuroplastic pain.
One other way (though not a perfect way) to distinguish between acute and chronic pain is response of the patients to usual medical interventions or surgeries. Acute pain tends to respond well to meds. Chronic neuroplastic pain usually does not.
The most exciting feature of chronic pain is that it CAN be made better. Our brains are adaptable. Neuroplasticity means that the brain pain pathways that are misfiring, CAN be rewired. And that is why I am excited to start bringing this knowledge to all the women with fibromyalgia who have not been able yet to improve their pain consistently. It can be done and I will show you how.
So in summary, in this blog we covered the difference between acute or plan/regular pain and chronic pain of fibromyalgia that is also referred to as “neuroplastic pain” or brain pain. Stay tuned for the next blog where I discuss how it comes to be.