CENTRAL SENSITIZATION AND FIBROMYALGIA
CHRONIC PAIN, CHRONIC ILLNESS, AUTOIMMUNITY, AND THE NERVOUS SYSTEM
Last month's issue of Practical Pain Management carried a featured article by Goldenberg titled New Insights in Understanding Chronic, Central Pain: A Guide for Better Recognizing Non-Cancer-Related Centralized Pain, which was essentially a dramatically scaled down version of his new book, Chronic Widespread Pain: Lessons Learned from Fibromyalgia and Related Disorders. Because CHRONIC PAIN is so prevalent, not only in America but around the world, it would behoove us to listen to what one of mainstream medicine's mouthpieces has to say.
Exactly how prevalent is chronic pain? Listen carefully. "It affects hundreds of millions of people, estimated at one-third of the world’s population at any single time." This pain used to be thought of as a perpetual aggravation of nerves by damaged tissue, along with the irritation of accompanying INFLAMMATION (the chemical messengers made by your immune system for the specific purpose of healing said damage). Goldenberg went on to reveal that this model became obsolete around Y2K, at that time receiving a new name. CENTRAL SENSITIZATION (aka Centralized Pain or Central Sensitivity) is named because of how it affects the central nervous system (CNS). In Central Sensitization, it's almost like the brain and nervous system "learn" pain, playing it over and over again, like an unholy cassette player whose auto-reverse feature has become stuck (those of you around in the 1980's understand what I mean).
The result is two characteristics I've spoken of many times --- HYPERALGIA & ALLODYNIA; the former being "an increased response to a noxious stimulus," while the later is described as "a painful response to a stimulus considered to be non-noxious". In other words, in people with Central Sensitization (CS), the result is that they can get severe pain for no good reason. Or they may have heightened responses to things that should maybe cause a bit of discomfort / pain, but are now instead causing severe pain. Part of the final kick in the teeth for sufferers is that Dr. Goldenberg describes fibromyalgia as "central pain's prototypic illness," something I've addressed on my site previously as well (HERE). After talking about something that the medical community has tremendous propensity for --- dividing and categorizing, he says....
"It has become increasingly clear that subdividing chronic pain into these four categories may be misleading since central pain is an important contributor to inflammatory, structural, and neurogenic pain. Pain categories are fluid and may change over time in a single individual."
Here is why understanding this quote is such a huge deal for those of you struggling with chronic pain. The statement above, for at least a significant portion of you, is the equivalent of Arnold Schwarzenegger's realization in 1988's classic, Predator. "IF IT BLEEDS, WE CAN KILL IT." This thought process --- a process I will come back to shortly --- becomes even more relevant when Dr/ Goldenberg lets us in on a critical tid bit of information; fibromyalgia is not the only health issue associated with centralization --- not by a long shot. He goes on to specifically mention FACE PAIN (SKULL PAIN), visceral or organ pain (along with perceptions of "peripheral organ dysfunction"), CHRONIC "TENSION" HEADACHES, TMJ, IRRITABLE BOWEL SYNDROME, INTERSTITIAL CYSTITIS and other similar pelvic pain syndromes, some of which are related to ENDOMETRIOSIS. What's even more relevant is that he also discussed both "structural pain and musculoskeletal pain." Once you start thinking of these in terms of both FASCIAL ADHESION (a huge factor with fibro --- HERE) and SUBLUXATION, it's easy to see why there could be confusion.
This is why despite everything you may have been told --- 'your case is hopeless,' 'there is nothing you can do about this,' 'get used to it because it's how you're going to spend the rest of your life,' or about a million others patients talk about --- there may be a solution for you, simpler than you ever dreamed possible. Something I wrote about HERE. This is because even though there are any number of symptoms (including those seen in SMALL FIBER NEUROPATHY), there is not yet a true "test" for fibromyalgia (although some FUNCTIONAL MEDICINE practitioners would successfully argue this point). Dr. Goldenberg went on to talk at length about fibro, providing some facts from peer-review.
"Fibromyalgia is the most common form of unexplained widespread musculoskeletal pain, affecting 2 to 6% of the global population. Chronic widespread pain not related to a specific structural disease, is even more common, affecting 5 to 15% of the population. There is no clear boundary separating chronic widespread pain from fibromyalgia. There is no known cause of fibromyalgia although various physical and emotional stressors may be precipitating factors. Mood and sleep disturbances and chronic fatigue are present in the vast majority of patients. Various physical and emotional stressors have been noted to be precipitating factors in fibromyalgia, raising the possibility of altered hypothalamic pituitary-adrenal axis function. This triad of symptoms should be considered part of the phenotype of central pain. Physical trauma, such as repetitive strain, obesity, and chronic inflammatory and immune disorders, such as rheumatoid arthritis, predispose to fibromyalgia and central pain. Fibromyalgia or chronic, widespread pain is more common in individuals with RA, as well as in each of the systemic connective tissue diseases, compared to the general population. The prevalence of fibromyalgia has varied from 15 to 40% in patients with rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, and ankylosing spondylitis. Evidence of central sensitization has been even more evident in each of the rheumatic diseases, including osteoarthritis."
Contrary to popular belief, there seems to be numerous fibro-induced changes seen on functional MRI's and brain scans, the most common being various forms of neurological atrophy ("decreased brain volume") correlated with the length of time and severity of the problem. I've shown you this research previously (HERE), which reveals that chronic pain sufferers (not just pain from fibro) have brains that when imaged, contain almost 10 times the degeneration and shrinkage of controls. Not surprisingly, another manifestation of this neurological disruption involves the above-mentioned HPA-AXIS as well as ADRENAL STRESS / FATIGUE. This helps explain why stress is a common trigger for fibro. It's critical to realize that this stress can come in numerous forms, including dietary stress (those with fibro almost always have devastating SUGAR & JUNK ADDICTIONS), physical stress in the form of REPETITIVE OR TRAUMATIC INJURIES (or even exercising to much --- HERE), emotional stress, immune stress from CHRONIC INFECTIONS (tick borne illnesses, the viruses that cause mono, strep, staph, etc), etc, etc, etc.
Something else we see in the highlighted paragraph is fibromyalgia's relationship to "immune disorders". This, folks, is talking about AUTOIMMUNE DISEASES, the most common-mentioned in this article being rheumatoid arthritis and IBS / IBD (you already knew IBD was autoimmune, but yes, IBS is as well --- HERE). As for the Chronic Inflammatory Degenerative Diseases mentioned above, HERE is a list of those as well. The other factor mentioned by Dr. Goldenberg that's commonly associated with fibromyalgia is chronic low back pain.
Not only is CHRONIC LOW BACK PAIN an American epidemic that's being fueled by inflammation, sedentary lifestyles and OBESITY, but "One-third of subjects with chronic low back pain also report symptoms consistent with fibromyalgia, and more than 40% of patients at spine clinics met the criteria for fibromyalgia." One other factor that needs to be addressed is joint replacements. While I am certainly not against joint replacements when warranted, one of the dirty little secrets in the field of medicine is that it can be extremely difficult to correlate the degeneration seen on x-ray or MRI with a patient's symptoms, including their severity (HERE). This helps explain why one of the risk factors for poor outcome with joint replacement is, you guessed it, fibromyalgia ("The presence of chronic, widespread pain has also correlated with poor outcome in subjects’ joint replacement"). And not surprisingly, we see that having fibromyalgia is also associated with heavy use of medications in the "BIG FIVE" category, particularly OPIOIDS.
IS FIBROMYALGIA AN AUTOIMMUNE DISEASE?
"This paper proposes that immunological aberration is likely and this may prove to be associated with an expanding group of novel vasoactive neuropeptides. Vasoactive neuropeptides act as hormones, neurotransmitters, immune modulators and neurotrophes. They are readily catalysed to small peptide fragments. They and their binding sites are immunogenic and are known to be associated with a range of autoimmune conditions. They have a vital role in maintaining vascular flow in organs, and in thermoregulation, memory and concentration. They are co-transmitters for acetylcholine, are potent immune regulators with primarily anti-inflammatory activity, and have a significant role in protection of the nervous system to toxic assault and the maintenance of homeostasis. Failure of these substances has adverse consequences for homeostasis. This paper describes a biologically plausible mechanism for the development of FM based on loss of immunological tolerance to the vasoactive neuropeptides. The proposed mechanism of action is that inflammatory cytokines are provoked by tissue injury from unaccustomed exercise or physical injury. This may trigger a response by certain vasoactive neuropeptides which then undergo autoimmune dysfunction as well as affecting their receptor binding sites. The condition may potentially arise de novo perhaps in genetically susceptible individuals. FM is postulated to be an autoimmune disorder and may include dysfunction of purine nucleotide metabolism and nociception."
The problem we get into with autoimmune diseases (many of which are simply categorized as "MEDICAL MYSTERIES" --- arguably the most common problems in all of medicine) is figuring out which specific tissue is being attacked. Although this can be determined in many cases by testing; since there are literally hundreds of thousands of potential immune system targets, a huge number of autoimmune reactions or diseases go undiagnosed because no one has developed a test for that specific entity. So, even though patients always have some sort of working diagnosis (it's the only way that insurance companies will pay physicians for ongoing treatment), huge numbers of these diagnosis are vague or outright incorrect. What we do know is that as you've already seen; fibro is intimately and strongly linked to large numbers of known autoimmune diseases, including many that we have not mentioned such as THYROID DISEASE, leading many experts to postulate that fibro is itself autoimmune.
Just the other day I saw a piece in Practical Pain Management on a (gulp) vaccine trial for fibromyalgia (FDA Approves Clinical Trial for Fibromyalgia Using TB Vaccine) in which they were giving people BCG (Bacillus Calmette-Guerin) because it is known to boost production of an immune system cell that actually helps suppress the runaway immune system reactions that often lead to autoimmunity (TREGS) --- a big reason that in most cases of chronic illness, "BOOSTING" one's immune system is contraindicated. Also, I am leery of vaccines since they have themselves been repeatedly shown to have a propensity for actually creating both autoimmunity (HERE) and fibromyalgia (HERE).
Just remember that there are thousands upon thousands of sufferers who are successfully addressing their fibromyalgia. However, in order for this to happen, people will have to be willing to step outside of the box. What do I mean? Simply stated, taking DANGEROUS DRUGS without addressing underlying dietary and lifestyle issues is a recipe for disaster. Sure, you'll feel better for awhile. However, the underlying pathophysiology remains unaddressed and as all of you sufferers already know, the meds are not a valid long-term solution (HERE is an example).
And while the experts continue to say that fibro is, for the most part, not an inflammatory problem, there are plenty of indicators showing that reducing SYSTEMIC INFLAMMATION is helpful; in many cases extremely helpful. While there are any number of ways to go about accomplishing this, I've created a generic post to help you get started making your own personalized "exit strategy" --- a way to get off the medical merry-go-round, start taking your life back, and hopefully reducing the pain (HERE and HERE). Oh; if you like our site or find yourself spending more time that you intended, be sure and give us some props on FACEBOOK since liking, sharing, or following is a great way to reach those you love and care about most.