I’ve asked it before, and I’ll probably ask it again, but does widespread pain really belong with the rheumatologists? I think the answer is rapidly becoming “No”.
The “so what” question begs: does it really matter who looks after people with widespread pain? I think the answer is “yes”, only because it’s becoming clear that helping unravel the problem of fibromyalgia (widespread pain) is going to take a different tack from looking at peripheral mechanisms alone. In fact, it could be that peripheral mechanisms are by and large irrelevant to this enigmatic disorder.
What is fibromyalgia?
Good question: there are clear diagnostic criteria for the disorder, but developed mainly for research purposes. In clinical terms, fibromyalgia is a little more tricky. Essentially, if a person says “I hurt all over”, and they also report unrefreshing sleep, foggy thinking, fatigue and sensitivity to multiple sensory modalities, chances are the person…
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Thankyou, that makes a lot of sense and is something my clients could manage. I have some clients who could understand the more complex scientific papaer better than I could but most of them, especially on their worse days with FM/ chronic widespread pain wouldn’t stand a chance!
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Pamela also happens to be a science writer!
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Good question! Rheumatologists tried to “own” this particular symptom cluster under the banner of fibromyalgia. Sad to say, my fellow rheumatologists failed to understand the nature of the monster they created. Many of them are now passing back people with this label to the primary health care practitioners. The problem was that they were unable to offer a cogent scientific explanation for their patients’ predicament. The current wisdom is that the condition now falls into the category of “polysymptomatic distress”. But a new hypothesis has emerged, which has the potential to improve understanding and advance research in this complex area of medicine. If you click on this link and scroll down to “An evolutionary stress response hypothesis for chronic widespread pain (Fibromyalgia Syndrome)” you will be able to freely access the paper. http://www.painaustralia.org.au/healthcare-professionals/research.html
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Thanks, I need to read and re-read that paper several times to make sense of some it I think. Lots of food for thought in what I have picked up. I can see that a greater understanding of rational for different treatments is one thing that might come from this work. I also hope that a good science writer can get in on this at some point to make it more accessible to those with chronic widespread pain.
As with so much in my work it is even more important than with many of my other clients to remember that any particular symptom or collection of symptoms does not have a one size fits all solution. One of my clients with this believes that liver problems mean she can’t use essential oils as part of the massage. I haven’t challenged this, partly because there is a chance it might be true but mainly because it is such a strong belief of hers. I do use them in a vaporiser in the room where the dose taken in by the body is orders of magnitude lower. Of the other three two find energising oils such as Rosemary helpful, whereas the third finds this exacerbates her pain and calming/anti-inflammatory oils such as Chamomile are more helpful.
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Try this version.
Evolution, Stress and Fibromyalgia
Adapted from: Lyon P, Cohen M, Quintner J. An evolutionary stress-response hypothesis for Chronic Widespread Pain (Fibromyalgia Syndrome). Pain Med 2011; 12: 1167-1178.
Despite affecting huge numbers worldwide and being researched extensively over 25 years, fibromyalgia syndrome (FMS) remains a problematic construct, for clinicians and patients alike. Characterised by persistent widespread pain and tenderness disproportionate to demonstrable tissue damage, of which there may be none, the syndrome often includes sleep disturbance, fatigue, ‘irritable bowel,’ cognitive and affective changes, and, less frequently, skin disorders. Without a cogent model of pathogenesis for this complex syndrome, effective treatment remains elusive. An evolutionary approach provides insight.
Several clinical features of FMS accord with “sickness behaviour,” found widely in the animal kingdom, which is the observable manifestation of physiological processes working to restore proper functioning. Sickness behavior is part of the organism’s response to some sort of stressor (threat, disturbance), which may be perceived via innate immunity or cognitively. The building blocks of the human stress response (i.e., cytokines, neurotransmitters, hormones) are evolutionarily ancient.
The systems that underlie the human stress response (SR) are multiple, co-modulatory and co-regulatory. Almost from the moment a SR is activated, countervailing processes also activate, to ensure that the dramatic molecular events marshaled to save the animal don’t damage the animal. This is because many molecular actors involved in SRs are ‘double-edged,’ and can have negative as well as positive effects on organism functioning. The response to stress thus is designed to engage, repair, and stop (resolve).
When an SR is prolonged in any organism, for whatever reason, profound changes occur in functioning and behaviour. Chronic SR activation in humans is associated with some of the most medically important diseases in the developed world, including cardio-vascular disease, type 2 diabetes, and metabolic syndrome.
One of the ‘double-edged’ molecules involved in vertebrate SRs and associated with a wide variety of chronic human diseases is substance p (SP), a deeply conserved neuropeptide also found in insects and molluscs.
In humans, SP operates in both the central and peripheral nervous systems. With its preferred receptor neurokinin-l (NK1R), SP is involved in a staggering range of defensive mechanisms, including cytokine release, cell manufacture and migration to sites of injury, mast cell granulation, edema, vomiting, gut contraction, cell death, and aversive reinforcement learning.
Its importance to human functioning is reflected in ontogeny: SP is one of the first neurotransmitters to appear in foetal development, before other SR actors, including corticotropin-releasing hormone, adrenaline, noradrenaline, dopamine, and serotonin.
The relevance of SP for understanding FMS is three-fold.
First, elevated SP in cerebral spinal fluid is the most reliable biomarker of FMS. Patients typically have SP levels 2-3 times those of healthy controls.
Second, SP is highly correlated with the common co-morbidities of FMS, including depression, sleep disturbance, irritable bowel and psoriatic skin disorders.
Third, recent research shows that SP is necessary for the development of central sensitization in the spinal cord’s dorsal horn. Central sensitization is widely thought to be the most promising explanation of how chronic pain is induced.
From this perspective, FMS can be seen as a clinical outcome of prolonged activation, or dysregulation of a complex, evolutionarily conserved system designed to defend the organism against threat. There are several explanatory benefits to such a view.
First, this perspective explains why a chronically activated or unresolved SR might manifest as labile widespread pain in association with other co-morbidities.
Second, it explains the clinical overlap of FMS with post-traumatic stress disorder, which is also associated with elevated CSF-SP.
Third, because SR systems are among the most genetically and phenotypically variable systems in biology, this perspective may help to explain the great differences between individuals in clinical presentation. SR systems in mammals are highly susceptible to modification in early development, producing different stress reactivity profiles, so childhood exposures to stressors, including serious disease or injury, may be relevant to clinical presentation.
The SP/SR hypothesis may help to explain why SP and NK1R antagonists did not fulfil their promise as treatments for FMS. SP/NK1R participates in many defensive systems important to whole-organism functioning, not just chronic pain, and they work in combination with many other molecules.
Finally, the hypothesis might also help to explain why certain holistic, non-pharmacologic therapies (e.g., patient education, cognitive-behavioural therapy, mindfulness/relaxation) appear to help a substantial proportion of patients, particularly when combined with exercise. It takes a system to treat a system.
Pamela Lyon, Visiting Research Fellow, Social Epidemiology and Evaluation Research Group, University of South Australia; Milton Cohen, Specialist Pain Medicine Physician and Rheumatologist, St Vincent’s Campus, NSW; John Quintner, Consultant Physician in Rheumatology and Pain Medicine, Pain Medicine Unit, Fremantle Hospital
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