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!