Chronic pain and diagnoses such as fibromyalgia (FM) have posed challenges for health care providers over the years. One in fifty Americans will be given a diagnosis of FM, so getting accurate diagnosis and treatment right most likely affects someone you know. Furthermore, FM is given credit for being the most common cause of generalized muscle pain in women between the ages of 20 and 55. The impact is immense. So, what’s the deal with FM and why is it seemingly so difficult to treat? The exact causes of FM are unclear but we know some associative information that helps. Current research suggests involvement of the nervous system, particularly the central nervous system (brain and spinal cord).
Risk factors that have shown to have influence with FM include: genetic predisposition, stress, dopamine dysfunction, abnormal serotonin metabolism, deficient growth hormone, psychological factors, physical trauma, sleep deprivation, and neuro-immuno-endocrine disorder. General medications targeting this disorder include SSRIs, anticonvulsants, muscle relaxants, and pain medication. Current best evidence for treating FM consists of aerobic and resistance exercise, appropriate medication, and cognitive behavioral therapy (education).
MYTHS AND TRUTHS REGARDING PAIN
To be enlightened about a socially complicated subject, we must take a strong look at the absolute misconceptions about pain found in society and by some health care professionals. The following are myths regarding chronic pain:
1) MYTH #1 – Pain = “Something is wrong with tissues of my body”
TRUTH – There are three main types of pain: mechanical, chemical, and bio-psychosocial. Pain can occur because of any of the three individually, or a combination of two or three. It is important for patients to understand however, that pain does not always mean that there is tissue damage. In conjunction with this concept, increased pain does not always equal more damage, it may be that the body’s alarm system is on high alert and, in turn, pain perception increases.
2) MYTH #2 – Mind- Body Split: Pain is either physical and “real” or the presence of pain must mean “it is all in the head”.
TRUTH – It is important to realize that tissues heal. Chronic pain is not necessarily related to ongoing tissue damage. Simply letting patients know that there is a difference between pain and tissue damage can be very empowering for them.
3) MYTH #3 – Nociception and pain are synonymous
TRUTH – Often times when we think of nociception we think pain or vice versa. Pain is not something that exists in the tissue itself. There are receptors that exist in the tissue that, if stimulated, cause the perception of pain. Therefore, anything that over-stimulates a nociceptive fiber causes a perception of pain. This can be an external stimulus, such as stepping on a nail, OR increased ion channels due to the bodies reaction to a perceived threat, like recollection of a past experience, stress, or lack of sleep.
4) MYTH #4– Pain is an input-driven system, meaning there has to be an external stimulus to initiate feeling of pain
TRUTH – There are many stimuli that cause or exacerbate the symptom of pain, some as simple as lack of sleep, past experience, or stress. Pain does not always come from an external stimulus such as stepping on a nail. For example, studies confirm that simply driving by an area where a person has been in an accident can reproduce symptoms felt at the time of the accident, years later after their symptoms have resolved.
UNDERSTANDING PAIN
Many patients diagnosed with FM experience pain. However, there is often no obvious explanation for the pain they experience. This is also the case with other chronic pain conditions. Research demonstrates that Pain Neuroscience Education (PNE) in conjunction with appropriately prescribed aerobic and resistive exercise and manual treatment, can significantly reduce symptoms in this patient population. In fact, studies show that a six mile run stimulates endorphin release that is equivalent to 10 mg of morphine. There are thresholds for both intensity (>50% V02 max) and duration (>10 min) of exercise required to elicit the phenomena of exercise analgesia.
It is important to understand that pain is 100% produced by the brain based on a perception of threat. FM is a multiple system output that is activated by an individuals specific pain map in the brain. This map is activated whenever the brain concludes that there is a threat and action is required. As an example, if you were to sprain your ankle in front of an on-coming bus, you would still able to sprint out of the way and your ankle does not perceive immediate pain. This occurs because the bus is obviously a bigger threat than the competing sprained ankle and the brain comprehends and processes that complexity rapidly.
Emerging research shows that explaining to patients their pain experience from a biological and physiological perspective of how the nervous system/brain processes pain will allow patients to move better, exercise better, and think different about pain.
TREATMENT
In general recommendations for Fibromyalgia treatment include the following:
- Frequency: Aerobic exercise 3-5 days per week, resistance exercise 2-3 days per week. Flexibility and Range of Motion exercises should be performed on a daily basis.
- Intensity: General recommendations for aerobic exercise as seen on a BORG scale apply to FM patients. Resistive exercises, start with low weight, about 10% of the individual’s maximum, and progress at a max rate of 10% increase per week as tolerated at a low to moderate intensity, for 10-15 repetitions.
- Time: Aerobic exercise: start with short bouts of 5-10 min to an accumulation of 20-30 min as tolerated with a goal to achieve 150 minutes total per week of moderate-intensity activity. Resistance exercise: perform one or more sets involving 10-15 repetitions per exercise.
- Type: Aerobic: participate in exercise with low joint stress, such as walking, nu-step, cycling, or swimming. Resistance Exercise: individuals with significant joint pain or muscle weakness may benefit from beginning with maximum voluntary isometric contractions around the affected joint and then progressing to more functional type exercises. A strengthening program should included all major muscle groups as recommended for healthy individuals. Flexibility exercise: perform stretching or range of motion exercises of all major muscle groups.
Studies show that patients under the supervision of a skilled physical therapist with knowledge of the above stated recommendations will have quicker, safer, and better outcomes than those without equivalent intervention.
PAIN GENERATORS
It is vital that as healthcare providers we understand the pain generators. Is it actual tissue damage, or is it central sensitization? Meaning the primary lesion or dysfunction is located in the cerebral hemispheres, brainstem, and or spinal cord (eg. chronic pain, FM, CRPS). Symptoms and sign clusters have been identified indicating patients are 486 times more likely to have a central sensation pain state if they have disproportionate pain, disproportionate aggravating and easing factors, diffuse palpation tenderness, and/or psychosocial issues. These individuals need to understand pain science and how the brain maps it and why they are hurting from a neuroscience perspective to succeed.
If you have patients that are experiencing the following signs and symptoms above and you are wanting to see further progress in combination with medication and alternative treatments, please schedule an appointment today at any of our Wright Physical Therapy locations. Contact Jono Barker ( jono@wrightpt.com )with any questions or needed clarification.
