Burning From The Inside Out: Life With Fibryomyalgia

Comfort is a concept many people take for granted, until it suddenly vanishes. In everyday life, it is not the norm to recognize and appreciate the feeling of being comfortable. Nothing is more uncomfortable than being in pain. Every day, up to 67 million Americans experience the effects of chronic pain, showing that this suffering is an unending symptom that needs more understanding and concern [1]. Chronic pain is debilitating, defeating, and presents differently in each and every person affected by it. The wide variety of chronic pain makes diagnosis and treatment quite difficult. In many cases, this mind numbing pain comes from a neurological disease characterized by musculoskeletal pain known as fibromyalgia. Fibromyalgia is a largely misunderstood and complex disorder that results in hyperalgesia, an increased sensitivity to pain meaning our brain and spinal cord process painful and nonpainful signals thus amplifying painful sensations.  Other symptoms include fatigue, sleep disturbances, memory issues, and mood disorders [2]. The solution seems clear: to provide maximum comfort to someone suffering from chronic pain so that they may return to doing what they love. To accomplish this a personalized treatment plan must be established. For people diagnosed with fibromyalgia, comfort is seemingly unattainable without a perfect treatment plan. Unfortunately, the history of fibromyalgia pain management has not been so simple. For decades, many healthcare professionals have neglected to properly manage pain due to subjective beliefs, and some have gone even further by gaslighting patients by denying the existence of fibromyalgia [2]. Claims of chronic pain are reduced to symptoms of other problems, thus extending the pain and damage. The scientific community does not fully understand the mechanical complexities of chronic pain, but this does not mean that just because something is not understood, it can be denied existence. If fibromyalgia presentation vastly fluctuates among the people affected by it, then how are effective treatment plans devised to reduce pain and increase one’s quality-of-life?

Clinical Symptomatology of Fibromyalgia 

In order to discuss the intricacies of fibromyalgia, it is important to understand the perspective of someone living with fibromyalgia. Having never ending body-wide pain is incredibly taxing both physically and mentally. The physical symptoms of fibromyalgia are mostly chronic pain and chronic fatigue. However, the emotional and neurological symptoms vary drastically including sleep disturbances, memory issues, and a host of different mental illnesses [3]. Fibromyalgia pain manifests in different ways for each person diagnosed. Some patients have generalized pain all over the body while some have more specific regions affected by chronic pain. Around 20-30 percent of patients experience what is known as paresthesia, better known as the pins-and-needles sensation [3]. This is like when a limb falls asleep. This occurs in one’s limbs, hands, or their torso on a regular basis [3]. Other manifestations of chronic pain include blurry vision, intense headaches or migraines, abdominal pain, irritable bowel syndrome, hypersensitivity to light, hypersensitivity to heat, and the list continues [3]. Clearly, chronic pain presents in a vast range of different ways, making it an incredibly difficult disease to diagnose. Furthermore, the comorbidity of fibromyalgia with anxiety and depression is immense [3]. Living with one of these symptoms is challenging but, experiencing multiple of them simultaneously is torture. An integral part of increasing the quality-of-life of someone with fibromyalgia is curating a sculpted treatment plan that maximizes pain reduction. Recently, there has been more success with this goal than in the past due to understanding of the disease’s symptoms and roots. 

Neurobiology of Pain

Pain is a sensation that we all experience to some degree, but what truly is pain in a neurobiological perspective? There are three different types of pain: nociceptive pain, inflammatory pain, and pathological pain [4]. All three forms of pain function within the nervous system, which is the connectivity of nerves that allows our bodies to receive stimulus and have the brain respond accordingly. The nervous system is split into two branches: the central nervous system (CNS) and peripheral nervous system (PNS). The CNS involves the nerves that make up the pathways of the brain and spinal cord, while the PNS consists of the nerve pathways within the rest of the body. Nociceptive pain is the classic form of pain based on a stimulus in the PNS that the brain tells us to avoid, like touching something hot, intensely cold, or sharp. This form of pain evolved from millions of years of evolution to guard from injury [4]. To protect from further damage from an injury, inflammatory pain evolved to heighten sensitivity at the site of injury. This allows the body to reduce the risk of compounding damage and promotes healing [4]. Finally, pathological pain is different from the other forms since it does not function to protect but is the result of dysfunction within the nervous system. Pathological pain can be identified by amplified feedback to non-harmful stimuli, showing a possible problem in the nervous system that results in abnormal instances of pain. However, it is also possible for pathological pain to occur in a nervous system with no damage [4]. Central sensitization is a term for dysfunction in the neural pathways that lead to and from the brain which results in pain amplification since many of the pathways work to minimize painful inhibitory mechanisms [5]. Many practitioners believe that fibromyalgia stems from a dysfunctional central nervous system via central sensitization, but the specific mechanics of action are yet to be fully understood [6]. It is known that the abnormal function in fibromyalgia patients results in both hyperalgesia and allodynia. Previously defined, hyperalgesia is exaggerated pain to normally painful stimuli, and allodynia is pain responses from non-painful sensations [6]. Stress also plays a large role in fibromyalgia since it can amplify pain experiences. Of many theories, there exists a hypothesis that childhood stress plays a role in the development of fibromyalgia [7]. This theory encapsulates the idea that while body-wide pain is difficult to treat, it becomes even harder to effectively treat in fibromyalgia patients because the causes of the condition are unclear. Previous studies have found that people with fibromyalgia do not respond to typical treatments of pain caused by damage or inflammation, like nonsteroidal anti-inflammatory drugs (NSAIDs), injections at the site of pain, or surgical intervention [6]. This type of pain is abundant in fibromyalgia, and there needs to be a therapeutic plan devised for effective management of pain in people suffering with persistent chronic pain. 

Historical to Modern Treatments of Fibromyalgia

Fibromyalgia is a prime example of a disease that results in systematic mistreatment. For decades, people who have suffered from horrific chronic pain alongside other symptoms of fibromyalgia have been turned away and gaslit by health professionals. Diseases are typically caused by some sort of pathogenic invader or bodily disorder causing dysfunction in organs and different body symptoms [2]. Fibromyalgia, however, has no specific target and no distinguishable biomedical model for trials in clinical practice, which makes it very difficult to classify as a disease. The inability to label fibromyalgia as a disease means less funding for research, less proper diagnosing by professionals, and unfortunately has made many physicians refute its existence [2]. Moreover, this is a vicious cycle because the less awareness and research dedicated to fibromyalgia, the less likely there is to be an effective treatment. 

However, this tale has shifted in the last thirty years as there has been an explosion in fibromyalgia research as it gains legitimacy. Through research and case studies of fibromyalgia patients, there has been a boom in connections discovered between physical pain felt with emotional pain experienced. Many patients have found pain relief through cognitive behavioral therapies by using coping mechanisms to minimize symptoms thus increasing quality of life [2]. Many patients work with a team of different specialists to find a balance between pain management therapies, psychotherapy, and holistic medicinal practices like yoga, meditation, or acupuncture to reduce overall pain and associated symptoms. This balancing act typically takes years to perfect on a patient-specific level with the chance of never finding the right balance [8]. The need for this variety of treatments further shows that, while effective, it is very difficult to treat fibromyalgia patients on a mass scale. Furthermore, there are advances in pharmacotherapy for fibromyalgia patients. The main drawback is there isn’t a “cure-all” medication, but different medications that control a few symptoms of fibromyalgia at a time. There are four broad classes of pharmaceutical therapies that are effective: anti-epileptic drugs (AEDs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) [2]. AEDs, TCAs, SSRIs, and SNRIs all work by changing the levels of ions and chemicals called neurotransmitters in the nervous system in some capacity. This results in changes in pain perception, mood, and even overall brain activity. Various other muscle relaxants, dopamine agonists, and experimental drugs have also worked. So far, only Lyrica (pregabalin), Cymbalta (duloxetine), and Savella (milnacipran) have been approved by the FDA for use in treating fibromyalgia [5]. There is no one perfect regime for curing fibromyalgia, but the narrative has changed in recent decades to provide the research needed to find better treatments.

A Possible Origin for Fibromyalgia

Trauma, and more specifically childhood trauma, has horrendous effects on the wellbeing of an individual at both the mental and physical level. “The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma'' is a New York Times bestselling book by the trailblazing trauma researcher Bessel van der Kolk. Van der Kolk’s description of the body ‘keeping the score’ is the perfect analogy for how childhood trauma could relate to fibromyalgia as well as countless other chronic diseases. Furthermore, childhood trauma in the form of abuse and neglect is far more common than many people realize, with 1 in 8 children in the United States being maltreated by the age of 18 [9]. A common way to measure childhood trauma utilized today is the Adverse Childhood Experience (ACEs) questionnaire. The ACEs questionnaire consists of questions about traumatic childhood experiences, and it can be theorized that the higher the score the higher the risk to develop health problems with aging [10]. Some of these health problems are pulmonary disease, coronary artery disease, hypertension, obesity, diabetes, autoimmune disease, liver disease, chronic pain, anxiety, and depression. These are all examples of the body keeping the score of the psychological stress endured from childhood maltreatment. Current research into the link between ACEs score and fibromyalgia coincides with the trend of higher ACEs score and fibromyalgia development [7]. The physiological reasoning for this is child abuse trauma can cause the central nervous system dysfunction seen in fibromyalgia [7]. More specifically, the stress associated with trauma can cause central nervous system sensitization and hyperalgesia [7]. This indication is significant in that it shows that there could be a very serious connection between mental and physical health.  It is important for health professionals as well as everyone else to recognize how trauma, while not only mentally damaging, can also be physically detrimental and cause unforeseen problems if not treated appropriately. 

More and more research into the neurological underpinnings of fibromyalgia have resulted in more understanding of the mechanisms that create pain responses which may lead to pharmacological treatments in the future [11]. Furthermore, holistic approaches to pain management as well as a balance of pharmacological drugs have proved very useful in pain reduction. Possible causes of fibromyalgia have shown that mental health needs to be treated the way physical health gets treated: immediately. The long-lasting stigma against the validity of fibromyalgia has been damaging to progress in treatment as well as the quality-of-life of patients. It is critical that the scientific community and medicine accept that there are diseases that are not understood, but that does not mean that they can be discounted as fake. Many physicians, researchers, and members of the health community do not take fibromyalgia seriously, and dismiss patients without providing proper care or treatment. This ideology is counterproductive to the core values of science and may cause more harm to already suffering individuals. However, a shift towards more open-mindedness could be extremely beneficial to those suffering from chronic pain. Recently, there has been a shift towards the importance of mental health and how mental well-being strongly relates to physical health. 

References:

1. Centers for Disease Control and Prevention. (2020, November 4). Products - data briefs - number 390 - November 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db390.htm

2. Häuser, W., & Fitzcharles, M.-A. (2018, March). Facts and myths pertaining to fibromyalgia. Dialogues in clinical neuroscience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016048/

3. Sarzi-Puttini, P., Giorgi, V., Marotto, D., & Atzeni, F. (2020). Fibromyalgia: An update on clinical characteristics, aetiopathogenesis and treatment. Nature Reviews Rheumatology, 16(11), 645–660. https://doi.org/10.1038/s41584-020-00506-w

4. Woolf C. J. (2010). What is this thing called pain?. The Journal of clinical investigation, 120(11), 3742–3744. https://doi.org/10.1172/JCI45178

5. Chinn, S., Caldwell, W. & Gritsenko, K. Fibromyalgia Pathogenesis and Treatment Options Update. Curr Pain Headache Rep 20, 25 (2016). https://doi.org/10.1007/s11916-016-0556-x

6. Sluka, K. A., & Clauw, D. J. (2016). Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience, 338, 114–129. https://doi.org/10.1016/j.neuroscience.2016.06.006

7. Gordon J. B. (2021). The importance of child abuse and neglect in adult medicine. Pharmacology, biochemistry, and behavior, 211, 173268. https://doi.org/10.1016/j.pbb.2021.173268

8. Tzadok, R., & Ablin, J. N. (2020). Current and Emerging Pharmacotherapy for Fibromyalgia. Pain Research and Management, 2020, 1–9. https://doi.org/10.1155/2020/6541798

9. Wildeman C, Emanuel N, Leventhal JM, Putnam-Hornstein E, Waldfogel J, Lee H. The Prevalence of Confirmed Maltreatment Among US Children, 2004 to 2011. JAMA Pediatr. 2014;168(8):706–713. https://doi.org/10.1001/jamapediatrics.2014.410

10. Starecheski, L. (2015, March 2). Take the ace quiz - and learn what it does and doesn't mean. NPR. https://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean