Getting to the Roots of Fibromyalgia Pain

Dr. Daniel Clauw is a rheumatologist and professor of anesthesiology and medicine at theUniversity of MichiganMedical School. A study he co-authored in 2002 found that fibromyalgia patients process pain differently from other people.

Q. Fibromyalgia is so hard for most people to understand. How do you explain it?

A. Fibromyalgia is real. But the pain isn’t occurring because of damage or inflammation in muscles and joints. It’s the result of differences in the way the brain and spinal cord process and transmit pain. It’s as if the volume control is turned up on pain.

Q. How so?

A. When I lecture on fibromyalgia, I point out to people that they’ve been sitting for 30 minutes. During that time, nerve endings in the back and buttocks have been firing constantly, sending messages to the spinal cord and the brain that there is pressure in those regions of the body. Since it’s not harmful, the brain sends back messages to ignore it. But if those descending messages aren’t as strong as they should be, a person may feel the pressure as painful, even when it shouldn’t be.

Q. So patients are hypersensitive?

A. A lot of what we’ve learned is that people are at different places on the bell-shaped curve of pain sensitivity. Some of the biggest naysayers contend that fibromyalgia isn’t a discrete disease because its presence or absence depends on where you draw the line on pain sensitivity. But in fact, we judge lots of diseases that way. There is a normal range for blood pressure and blood sugar. Outside that range, if it’s too high or too low, it causes problems.

Q. If there are no objective tests for fibromyalgia, how can you prove that patients are truly processing pain differently?

A. There are three lines of evidence.

In 2002, Richard Gracely and I published a study in Arthritis and Rheumatism that provided the first objective corroboration. We did brain scans on people with and without fibromyalgia while applying carefully calibrated pressure to the thumb. The fibromyalgia patients showed much greater activation in the brain with the same level of pressure. To evoke the same response in people without fibromyalgia, we had to use twice the pressure.

Since then, three other studies have shown hyper-reactivity in parts of the brain that are involved in processing pain. These are the regions that tell us where the pain is and how much of it we’re experiencing — the primary and secondary somatosensory cortices, the thalamus and the posterior part of the insula.

Q. For the sake of argument, couldn’t you make a case that if patients simply believe something is more painful, they will have more activity in these brain regions? After all, thought itself is represented by activity in the brain.

A. Only in part. There have been imaging studies of people under hypnosis, in which patients were tricked into thinking that pain was increased or reduced. You see some changes on brain scans, but not the same widespread hyper-reactivity that you see consistently in fibromyalgia patients.

Q. You said there were three types of evidence. What’s the second?

A. Rick Harris in our group is using a type of brain imaging that allows you to look at the levels of [brain chemicals called] neurotransmitters. We’re particularly interested in glutamate, a neurotransmitter that increases pain transmission. He’s found that levels are higher in the brains of people with fibromyalgia.

At the same time, patients have lower levels of neurotransmitters that reduce pain transmission, including norepinephrine and serotonin. There are 5 to 10 of these substances that turn up the response, and 5 to 10 that turn it down. It’s a yin-yang effect.

One of the other big advances in the fibromyalgia field is the discovery that substance P and nerve growth factor — chemicals that increase pain transmission — are two to three times higher in the spinal fluid of fibromyalgia patients. All these imbalances may be responsible for their hypersensitivity.

Q. Do these screening techniques provide the type of objective tests doctors are looking for?

A. You could use them to confirm a diagnosis, but they’re not specific for fibromyalgia. The same responses are found in other chronic pain states, such as migraine headaches.

Q. That would tend to confirm that fibromyalgia pain is real, not imagined.

A. The other thing that’s sobering is that imaging studies of patients show brain atrophy in regions that are involved in pain processing, suggesting that if you have chronic pain syndromes too long, you get permanent changes in brain structure. Early diagnosis and treatment may be very important.

Q. Do genes contribute to fibromyalgia?

A. That’s the third line of research. It shows that chronic pain is strongly genetic. There have been twin studies in the last year from huge twin registries in Sweden, looking at fraternal and identical twins, raised together or apart. The researchers have then teased out the relative contributions of genes and environment — nature and nurture — and found that 50 percent of the risk of developing chronic pain is genetic and 50 percent is environmental.

But the really cool thing is a 2004 study by Lesley Arnold at the University of Cincinnati. She identified a group of people with fibromyalgia. She then examined their first-degree relatives and found that the relatives were eight times more likely to have fibromyalgia than family members of people without the disease. That’s enormous. If you do exactly the same type of family study on people withrheumatoid arthritis or lupus, the odds of having a first-degree relative with the disease is between two and three times greater, not eight.

Even if family members didn’t have fibromyalgia, they tended to have more pain in general, suggesting that the volume control problem runs in families.

Q. Have specific genes been identified?

A. Four different gene variants are found in higher levels in patients with fibromyalgia, including a variant of the COMT gene. This gene is associated with pain sensitivity in a number of pain conditions. There was just a nice study in Arthritis and Rheumatism showing that in a big database of people with osteoarthritis of the knee, the presence or absence of this gene variant was strongly associated with pain sensitivity, especially in women. The gene is known to be estrogen-sensitive.

Q. If COMT is estrogen-sensitive, could that help explain why women are more likely than men to suffer from fibromyalgia?

A. Possibly, but it would require more research to make that determination.

Q. If 50 percent of the risk for fibromyalgia is genetic and 50 percent is environmental, what are the environmental factors that trigger the disease?

A. Almost any biological stress can trigger pain in people who are predisposed — infections, surgery, car accidents, falls, prolonged stress. There was a really good study last year by a group in the U.K. They looked at a population of 50-year-olds with chronic widespread pain and compared them to a group without. Because of the British national health system, they were able to go back and examine medical records for the same patients from 42 years earlier. At age 8, the patients who later developed fibromyalgia were 1.5 to 2 times more likely than controls to have been in a car accident or to have had prolonged hospitalization.

It’s a cool time to be a pain researcher.

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Doctor Admits Vaccine Is More Deadly Than Swine Flu Itself

Alternative Therapy Looks Promising

A mysterious ailment that afflicts both women and men with a range of symptoms that include pain, fatigue, poor sleep, tingling and memory problems. Diagnosis can take a long time and there is no cure. Though about a third of patients respond to F.D.A.-approved drugs for the condition, many more seek relief through lifestyle changes and alternative and complementary therapies.

This week Dr. Brent Bauer, director of the complementary and integrative medicine program at the Mayo Clinic in Rochester, Minn., joins the Consults blogs to answer readers questions about fibromyalgia. Dr. Bauer writes:

Fibromyalgia is a vexing condition for both patients and doctors. It’s vexing for patients because it can cause symptoms ranging from mild muscle aches to debilitating pain, yet it remains poorly understood and has no known cure. It’s vexing for many physicians who are faced with suffering patients but have only a limited armamentarium of treatments to offer.

The good news is that research is growing – revealing many new strategies for dealing with fibromyalgia in a way that helps many patients live with the disease successfully.

One exciting area of research in the past decade has been in the realm of complementary and alternative medicine, or CAM, treatments for fibromyalgia. These range from well recognized therapies like acupuncture and massage to more novel treatments like d-ribose and qi-gong.

As this research grows, it is increasingly possible to identify CAM therapies that have some evidence of efficacy and minimal risk that can be incorporated right along with the more conventional treatment recommendations. This blending of the best of evidence-based alternative medicine with the best of conventional medicine is typically referred to as “integrative medicine” – since it is an integration of both for the benefit of the individual patient.

In fibromyalgia, this might mean taking your prescribed medication while adding in a massage once a week or pursuing a gentle, graded exercise program while you also receive acupuncture treatments. By working with your care team, you may be able to find a new combination of approaches that fit your lifestyle while addressing your unique needs.

The Long Search for Fibromyalgia Support

Today's guest blogger is,

"Psychology of Pain". 

Created by Gary B. Rollman, Professor of Psychology, University of Western Ontario, London, ON. 

I'm sure a lot of us can relate to Glenn and Judy's story.

Fibromyalgia - Reporter's File - The Long Search for Fibromyalgia Support - NY Times Health

Glenn Robinson was always physically affectionate with his wife, 

Judy. But after she underwent abdominal surgery four years ago, 

everything changed.

Long after the incision healed, Judy had pain in her hips, her lower 

back, her legs, her muscles, her skin. When Glenn tried to tickle or 

squeeze her, she would shy away. Hugs would elicit a grimace. "Don't 

touch me; it hurts," she would say, backing off. Glenn reacted the 

way any husband would. "I got angry," he said.

The couple's social life ground to a halt. Judy, 48, began begging 

off picnics, barbecues and trips to the boat races at Belle Isle Park 

in Detroit, where they live.

"We would make plans to get together with friends for dinner," said 

Glenn, 50. "Come that day, beautiful weather, she wouldn't want to 

leave the house."

There were days when Judy didn't even want to talk on the phone. And 

though she soldiered through eight-hour workdays in the shipping and 

receiving department of a leather company, she would take breaks to 

sit in the bathroom and cry.

The Robinsons became desperate to find out what could possibly be 

causing Judy's pain. M.R.I.'s turned up nothing more than a herniated 

disc or osteoarthritis. Both can be excruciating, but neither could 

account for the pains Judy felt all over her body. Her doctor 

prescribed narcotics, but even those didn't help. It hurt to wash her 

face. It hurt to raise her arm. It hurt to sleep. It still does.

"If you touch my back, it feels like it's all bruised," she said. 

"Lately it's felt like electroshocks."

In March 2009, after four years of suffering, Judy finally found a 

new doctor who could name her ailment: fibromyalgia.

If there is a circle of purgatory that Dante forgot, it might be the 

one reserved for fibromyalgia sufferers. The problem isn't just 

pervasive pain. It's the challenge of having a condition that is not 

well understood. It doesn't help that there is no objective medical 

test to confirm it — no blood test, no cheek swab, no X-ray — just a 

patient's subjective reports. Nor does it help that there is no cure. 

Many physicians don't want to be bothered with incurable patients.

If doctors don't sympathize, why would friends? How do you explain to

people that you have no broken bones or burns or even infections, yet 

your body hurts all over? You look fine, yet beg off work and social 

engagements. Are you a malingerer? Are you just trying to claim 

disability? Are you simply crazy? And why don't you get better?

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Upbeat Music Thursday

Doctors Often Misdiagnose Celiac Disease

I found this article to be interesting. The part about how every person diagnosed with Irritable Bowel Syndrome should be tested for celiacs disease and the cause of the disease is an intolerance to gluten, a protein found in wheat, barley and rye. 

Dear Dr. Donohue: My husband has celiac disease. We are very much aware of how often it is ignored, misdiagnosed and mistreated by the medical profession. You recently discussed irritable bowel syndrome, which has symptoms similar to celiac disease. Please mention celiac disease so the possibility will be investigated.

R.E.

Dear R.E.: Hearing about celiac disease as a medical student, I thought I could tuck it away in a back file, since I would never see it. That was a wrong impression. It's a common disorder that often is misdiagnosed because its symptoms are mistaken for other illnesses, one being irritable bowel syndrome.

Diarrhea, weight loss, fatigue, bloating and crampy abdominal pain are celiac disease's most conspicuous symptoms. However, many celiac patients don't have dramatic symptoms. They might see the doctor for osteoporosis, because celiac disease interferes with calcium absorption. Or they might have an iron-deficiency anemia because of that mineral's malabsorption. Often, a celiac patient's symptoms are those of irritable bowel syndrome, and the patient is given treatment that does nothing for celiac disease.

Many doctors feel that all who are diagnosed with irritable bowel syndrome should have the simple blood test for celiac disease. If that test is positive, further testing with a small bowel biopsy confirms the diagnosis.

Celiac disease is an intolerance to gluten, a protein found in wheat, barley and rye. In intolerant people, gluten activates the immune system, which attacks the digestive tract. Treatment is a gluten-free diet. In the early stages of treatment, oats are often banned because during refinement, they're frequently contaminated with one of the gluten grains.

A gluten-free diet is somewhat difficult to master and is somewhat constricting in the food choices it allows. However, the Celiac Disease Foundation stands ready to help people master the diet. Contact the foundation at (818) 990-2354 or on the Internet at www.celiac.org.

Dear Dr. Donohue: My older brother died in a mobile home fire in Alaska. Enclosed is a copy of his autopsy. It states the cause of death as "hypertensive and atherosclerotic cardiovascular disease with smoke inhalation contributing to it." I find no evidence of heart attack or stroke in the report. The Internet does not indicate that a carbon monoxide level of 34.9 percent is a fatal level (his level). Please explain.

S.C.

Dear S.C.: Your brother had signs of an old heart attack (lateral wall myocardial infarction). His heart arteries were severely clogged, showing from 90 percent to 99 percent blockages. His heart was twice the normal size, most likely a result of high blood pressure. A heart with such advanced disease and so starved for blood is liable to develop lethal heartbeats from the level of carbon dioxide found in his blood. Smoke, in addition to carbon monoxide, contains other noxious gases that added to the burden of an already overburdened heart.

Carbon monoxide displaces oxygen from red blood cells. The red blood cells grab onto it in preference to oxygen. His heart suffered a great oxygen deficit from the carbon monoxide and from the tremendously reduced blood supply to his heart.

You have my deepest condolences on your brother's death.

Dear Dr. Donohue: Years ago, Carmen Miranda sang to us to not put bananas in the refrigerator. Why? Are we supposed to leave them on the counter to attract fruit flies? Personally, I like a cold banana. What to do?

G.J.

Dear G.J.: I remember the banana advertisement. It went something like: "Bananas like the climate of the very, very tropical equator, so you should never put bananas in the refrigerator."

You'll be happy to know Carmen's advice no longer holds true and really never did. You can put bananas in the refrigerator. They last longer. Their peels might turn brown, but the bananas themselves stay fresh.

Your health Write to Dr. Paul Donohue at P.O. Box 536475, Orlando, FL 32853-6475.

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Simple Meditation Technique

The following is a very simple meditation technique you can learn in five minutes.

First, Sit Upright

Sit upright with a straight spine, away from the back of the chair. Place your feet flat on the floor, and your arms, palms turned upward, at the joint between your thighs and torso.

Relax the Body

Do this Tense and Relax exercise to help you relax the body:

• Inhale sharply through the nose, with 1 short and 1 long inhalation (double breath)
• Tense the whole body until it vibrates with energy
• Hold your breath and the tension for five seconds
• Exhale forcibly through the mouth, with one short and one long exhalation (double breath)
• As you do, throw the tension out
• Repeat several times

Breathe Evenly

Inhale slowly, counting to eight. Hold the breath for eight more counts, then exhale slowly to the same count. Without pausing, inhale again — hold — exhale, each to the count of eight. 

This is called the Measured Breathing Exercise. Repeat it three to six times.

You can vary the count according to your lung capacity, but always keep it equal during inhalation, holding, and exhalation. Finish your practice by inhaling deeply, then exhaling completely.

Hong-Sau Technique of Concentration

Now wait for the next breath to come in of its own accord. When it does, mentally say Hong (rhymes with song). This time, don’t hold the breath, but exhale naturally. As you do, mentally say Sau (rhymes with saw).

Hong-Sau is an ancient Sanskrit mantra (a mantra is a word, syllable, or group of syllables, which can convey spiritual power when pronounced correctly, often with repetition). It means “I am He” or “I am Spirit.” Try to feel that your breath itself is silently making the sounds of Hong and Sau.

Make no attempt to control your breath. Simply observe it as it flows in and out naturally.

In the beginning you may be mostly aware of the physical manifestation of the breathing process as your diaphragm and chest expand and contract.

As your breath grows calmer, however, try to become aware of its flow in the nostrils, then gradually transfer your awareness higher and higher in the nasal passages.

With the eyes closed, turn your gaze upward to the point midway between the eyebrows within your forehead. Concentrate there. This is the seat of spiritual consciousness in the body, also called the spiritual eye, or Christ Center. In time, try to feel the flow of the breath near the spiritual eye within your forehead.

Keep your gaze steady at the point between the eyebrows throughout your practice. Don’t allow your eyes to follow the movement of the breath. If you find that your mind has wandered, gently bring it back to an awareness of the breath and the mantra.  

Finish your practice of Hong-Sau by inhaling once through the nose, then exhaling three times through the mouth.

Meditation Proper

Forget the breath. Concentrate deeply at the point between the eyebrows. Keep your mind focused and your energy internalized. Absorb yourself in the peace generated by your practice.

Continue for at least five minutes. Finish with a prayer to the Divine, offering yourself into the light of God.

Ways to Deepen Your Meditation

1. Relax the Body

It is common for new meditators, in an effort to concentrate, to tense the body unconsciously. Deep concentration, however, is possible only in a state of complete relaxation.

Practicing the Tense and Relax exercise is an effective way to release stored-up bodily tension. Together with the Measured Breathing Exercise, these are preliminary exercises taught by Yogananda to help prepare the body and mind for meditation.

2. Pray

Begin your meditation with a prayer. This will help you remember why you are meditating! You will also be inviting the Divine, or your Higher Self, to help you in your practice.

3. Sit Perfectly Still

Moving your body even the slightly sends the energy into the muscles. The purpose of yoga is to withdraw that energy inward and upward, to the brain. Thus, any physical movement during meditation will counteract your meditative effort.

To keep yourself from fidgeting, try to think of your body as a rock-solid and unmoving. Refuse to move for the first five minutes of meditation, and you will find that your body will grow calm of its own accord.

Your physical and mental restlessness will subside the longer you sit still. A glass of muddy water will become clear in time if it’s undisturbed. The same is true for us!

4. Eye Position

Your eyes should be closed and held steady, looking slightly upwards, as if looking at a point about an arm’s length away and level with the top of your head.

It is essential to keep your gaze gently raised to that point throughout your practice. This will magnetize your spiritual eye, and draw the energy to the highest spinal center, the seat of spiritual awakening in the body.

5. Do Not Control Your Breath

After the preliminary breathing exercises, you should cease any effort to control the breath. Let it flow naturally. You may notice that the pauses between the inhalation and exhalation are gradually becoming longer.

Enjoy these pauses, for they are a glimpse of the deep state of advanced meditation. As you grow very calm, your breath may become so shallow, and the pauses so prolonged, that it hardly seems necessary to breathe at all.

Do not be alarmed. This is good!

How Long to Meditate

It is entirely up to you. Make sure, however, to allow enough time after the Hong-Sau practice to sit still and enjoy the calm meditative state.

Where to Meditate

If possible, set aside an area that is used exclusively for meditation. In time it will become saturated with spiritual vibrations. A small room, a corner of your bedroom, or even closet can suffice, as long as it is well ventilated.

Keep it simple. All you really need is a chair or small cushion to sit on, and perhaps a small altar. Face East if possible, and place a wool or silk blanket on the floor to insulate your body from the sublte magnetic currents of the earth.

Proper Meditation Posture

In addition to sitting on a straight-backed chair, there are other ways of sitting that are appropriate for mediation. You can sit on the floor in any of the several poses: cross-legged, half-lotus pose, or full-lotus pose.

Two things, however, are essential: your spine must be straight, and you must be able to relax completely without slouching.

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Meditation Music Monday

14 year old Katie The Deer Hunter

I'm not a big fan of hunting, but thought this was a great article to share.

My 14-year-old daughter, Katie, got a late start as a deer hunter, but it wasn't her choice. Prior to November 2008, she had been unable to hunt due to juvenile fibromyalgia. During that year and a half, we had to take her out of school three times and home-school her because she'd missed so many days.

Last year, eager to take her on her first hunt, I had a scope mounted on a 20-gauge shotgun that she could use, but she was never well enough to shoot it. In 2008, however, she was able to shoulder and fire it just a few days before Ohio's youth gun season.

That's when we learned she's left-eye dominant. After switching to shooting left-handed, Katie was able to touch part of the bull's-eye with her last two shots. I proclaimed her "ready."

We no longer live in the county where we hunt, so I had to roust Katie just after 3 a.m. on Nov. 22. Even so, we were more than a half-hour late getting to our hunting area.

Upon our arrival there, I got Katie geared up (the temperature was somewhere below 16 degrees) for her first hunt of any kind. Afterward, while I was gathering my own gear, Katie said she was nauseous and felt lightheaded. I lowered the tailgate so she could sit down for a bit.

She looked miserable, but she didn't want to go home.

As we prepared our spot on the ground by clearing out sticks, branches and leaves, a deer snorted at us from the next hill, probably 200 yards away from us. At least we had company!

After loading the Remington 1100 youth model, I set up a 2-foot-high turkey blind I'd brought. The flimsy rods almost didn't penetrate the frozen ground.

I had Katie practice aiming with her shooting stick, as the terrain was hilly and she would have to adjust its height depending on which direction she might have to shoot and how far up- or downhill a deer might be. A large fallen oak treetop still laden with leaves helped complete our hiding place.

About 15 minutes after we were situated, Katie spotted a yearling doe. I asked her if she wanted to take it, but she wanted a buck. We watched the wary doe pass within a few yards.

Katie's back became sore from being so still, so I supported her with my hands.

Soon afterward, Katie spotted two more does near where she'd seen the first. When they left, I saw that a big buck was trailing them. I told Katie to get ready for a shot. The buck stopped broadside uphill and looked our way. Katie was ready. I asked her if she had a clear target. She said she did, so I told her to shoot.

The great 6x4 ran forward and a little closer, and Katie fired again. A third shot anchored it, though there was really no need. The first slug would've been enough; it entered behind the shoulder. The second shot entered right beside the first.

--Dan Nethers

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