Chronic Pain – Is It All in the Brain?

Connie A. Luedtke, MA, RN-BC Assistant Professor at Mayo Clinic College of Medicine Nursing Supervisor at the Mayo Clinic Pain Rehabilitation Center and Mayo Fibromyalgia and Chronic Fatigue Clinic

For Webinar Series:

Chronic Pain - Improving Life While Living It

CIRB2012

We acknowledge the financial assistance of the

Province of British Columbia

Objectives After completion of session, participants should be able to: 1. List one difference between the old and new

criteria for diagnosing fibromyalgia 2. Identify two components of sensitization that

may be present in people with fibromyalgia 3. Describe three skills that may decrease

symptoms or improve functioning in people with fibromyalgia

by Hans Christian Andersen Illustrated by Edmund Dulac

Barbara Keddy, BSc.N., M.A., Ph.D., Professor Emerita, School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada.

Fibromyalgia as a Syndrome

Fairly consistent pattern of symptoms seen in people with the same medical disorder No defined cause More difficult to treat

Image from Mayo Stock Photos

Facts about Fibromyalgia

Not life threatening More commonly diagnosed in women May coexist with other treated medical

conditions

Image from Mayo Stock Photos

Facts about Fibromyalgia

Symptoms can fall on a spectrum – Generally include: Pain, stiffness, generalized flu-like achiness Pain sites that migrate May include chest pain Peripheral numbness and tingling Fatigue And others

Continuum of Pain and Fatigue Fibromyalgia

– chronic widespread pain, fatigue, unrefreshing sleep, cognitive and affective complaints

Chronic Fatigue (Multifactorial) – chronic fatigue or "chronic tiredness" related to chronic conditions, chronic

pain, deconditioning, sleep, or affective issues

– In the majority of cases, there are multiple contributors Chronic Fatigue Syndrome (CFS)

– physical and mental exhaustion of unknown etiology that profoundly impacts

physical, occupational, social, and psychological function.

http://mayoweb.mayo.edu/fibromyalgia/index.html

1990 American College of Rheumatology (ACR) Diagnostic Criteria:

Widespread pain on both sides of the body (above and below the waist)

Present for at least three months 11 out of 18 “Tender Points”

Tender Points

2010 ACR Fibromyalgia Diagnostic Criteria:

Widespread Pain Index

Symptom Severity – Fatigue – Waking unrefreshed – Cognitive symptoms

Additional symptoms Symptoms present at a

similar level for at least three months

Mayo Clinic form developed based on ACR criteria

What Causes Fibromyalgia?

No single event is known to cause fibromyalgia or chronic fatigue Combination of physical and/or

emotional stressors Considered a disorder of pain and/or

stress regulation

Genetic Predisposition Poor

Sleep

Physical Trauma - Peripheral

Nociception

Infections Inflammation

Other Factors

ANS Dysfunction

Psychological Factors –

Stress

Neonatal or Childhood Trauma

Environmental Noise

Chemicals Others

Hyper-excitement of Central Neurons

Central Sensitization

Modified from Yunus 2007, Simplified Bio-psycho-social model

SLEEP

MOOD

PAIN

FATIGUE

Autonomic Nervous System

Sympathetic – Initiates stress response

Parasympathetic – Initiates relaxation

response Balance is disturbed by

chronic stress

http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/A/auto nomic.gif

Stress Level Response

Time

Breaking Point S

S S

S S

S

S

S

S S

S

S

S

S

S S

P P P P P P P P P P P P P P P

Effects of Chronic Stress

S= Sympathetic P= Parasympathetic

Research Suggests….

CENTRAL SENSITIZATION: • Increase in the excitability of

neurons within the central nervous system

• Results in an abnormal

enhancement of pain and general hypersensitivity

Sensitivities Heightened response to any stimuli:

Light Sounds Smells Stress Touch Pain Foods Medications

Matthew Smith MD 2010 New York University Pain Management Team

Possible Overlap of Syndromes

Central Sensitivity Syndromes Irritable

Bowel Syndrome

Interstitial Cystitis Multiple

Chemical Sensitivities

Depression PTSD

Restless Leg Syndrome

TMJ

Fatigue

Fibromyalgia Myofascial

Pain

Migraines Tension Headaches

Postural Orthostatic Tachycardic Syndrome

Modified from Yunus 2007

Chronic Pain

Problems

How You Feel Acute Pain

Pain source

Nerve cells in spinal cord release chemicals to amplify or subdue pain message

Brain interprets the message as pain

(Mayo Clinic on Chronic Pain)

Electrical impulse moves through nerves to the spinal cord

How You Feel Chronic Pain

Chronic condition, injury or unknown

Possible chemical imbalances that affect pain response

Brain interprets the message as pain

(Mayo Clinic on Chronic Pain)

Nerve(s) sometimes misfire and send wrong messages

NORMAL

IMBALANCED NEUROCHEMICALS

OVER TIME..

Adapted from: Nijs J, et al: 2011

In our brains, neurons fire and synapse with one another….

…and repeated signals can create memory pathways.

http://brainmind.com/TemporalLobe.html

But wait! Our brains are neuroplastic!

http://brainmind.com/TemporalLobe.html

How does Neuroplasticity Work?

Neuroplastic y made simple http://www.youtube.com/watch?v=tJ93qXXYRpU

Focusing on: What Can I Control?

Activities of daily living Healthy choices Emotional responses Balancing the use of

time - family, leisure, work, exercise, spirituality

Self-Management Tools

Positive ThinkingDecrease

Symptom Focus

Relaxation

Stress Management

Moderation

Time Management

NutritionExercise

Spirituality

Leisure/Fun

Humor

Socialization

Communication

Sleep Hygiene

Mayo Clinic

What is Self-Management?

Holistic approach using the body, mind and spirit to decrease symptom burden and improve quality of life Key to living with fibromyalgia and other

chronic symptoms

Managing Symptoms Dampeners

– Relaxation – Regular exercise – Good sleep hygiene – Decreasing

perfectionism – Positive outlook – Humor – Balanced nutrition – Healthy boundaries – Meaningful free time

activities

Amplifiers – Muscle tension – Decreased activity/exercise – Poor sleep hygiene – Unrealistic expectations – Procrastination – Negative thinking – Symptom focus – Unhealthy eating – Withdrawal/isolation

Symptom Focus Behaviors

Things people say or do to communicate symptoms A focus on symptoms, signals

brain to chemically intensify the symptoms (Ex. Substance P) Responses from others can

inhibit healthy behavior – Changing solicitous and/or punitive

responses to a neutral response

Selective Attention

Negative Affect such as anxiety can increase

pain processing in brain

Can also be “unlearned”

Pain and Panic from Disney ©

Visualization of Pain

Focusing on pain and symptoms can cause physical changes in the body… ***which actually MAKES THE SYMPTOMS WORSE! MRI examples of focusing on pain

http://www.youtube.com/watch?v=oq6YKqSzEUw

Influence of Family Members “Enhanced state of awareness of significant others

regarding the pain behaviors of the focal person: a hypervigilance regarding these pain behaviors associated with solicitousness…”

During f-PET scans even the presence of a significant other caused increased pain perception

Cycle of soliciting and punishing needs to be broken by use of warm, firm neutrality

Reactions to Pain Behaviors

Solicitous •Overly care-taking

•Asking about pain

•Take on more responsibility

•“pillow fluffers”

*Neutral*

•Not asking about the pain

•Diversion or Distraction (redirect focus)

Punitive •Try to help but can’t

•Frustrated

•Angry/Resentful

•Guilty

Build Supportive Relationships Focus on the “person” not

symptoms Effective communication

– Being open and honest – Assertiveness, not

aggressiveness – Use “I” statements

Work on maintaining intimacy – Caregiver/patient vs. partners

What about Medications?

Meds helpful for “jump-start” Some types of antidepressants for pain, mood

and sleep enhancement Beta-Blockers can stabilize POTS symptoms Anticonvulsants for neuropathic pain Opioid use over time contributes to hyperalgesia

Medications

Milnacipran (Savella) is the latest drug to receive FDA approval for management of fibromyalgia. The FDA approved fibromyalgia indications

for pregabalin (Lyrica) and duloxetine (Cymbalta) — in 2007 and 2008 Outside the USA, milnacipran already has a

track record as an antidepressant.

Medications

Milnacipran is similar to duloxetine in that both drugs increase the supply of serotonin and norepinephrine (chemical messengers, also known as neurotransmitters) available to your brain. Milnacipran gives your brain a larger boost

in norepinephrine ("norepinephrine selectivity”).

Medications

Milnacipran is similar to duloxetine in that both drugs increase the supply of serotonin and norepinephrine (chemical messengers, also known as neurotransmitters) available to your brain. Milnacipran gives your brain a larger boost

in norepinephrine ("norepinephrine selectivity”).

Treatment Options No “magic bullets” Stop searching for “fix” Exercise Moderation Structured schedule Cognitive behavioral therapy Decrease symptom focused

behaviors

Manage stress Relaxation / Sleep hygiene Balanced nutrition/hydration Humor / Positive Self Talk “Warm Neutrality” from

family and support to make lifestyle changes

Self-Management Tools

Positive ThinkingDecrease

Symptom Focus

Relaxation

Stress Management

Moderation

Time Management

NutritionExercise

Spirituality

Leisure/Fun

Humor

Socialization

Communication

Sleep Hygiene

Mayo Clinic

The Ball is in Your Court!

References Keddy, Barbara (2007). Women and Fibromyalgia, Learning

to Live with the Invisible Dis-ease. ISBN: 978-0-595-44371-0.

Matthew Smith MD (2010) New York University Pain Management Team

Nijs J., van Wilgen, C.P., Van Oosterwijck, Jl, van Ittersum, M., Meeus, M. (2011). How to explain central sensitization to patients with ‘unexplianed’ chronic musculoskeletal pain: Practice Guidelines.

References Phillips and Clauw (2012) “Central Pain Mechanisms in

Chronic Pain States – Maybe it is All in Their Head.” Best Pract Res Clin Rheumatol. Apr 2011; 25(2): 141–154. doi: 10.1016/j.berh.2011.02.005

Rome and Rome, (2000) “Limbically Augmented Pain Syndrome (LAPS): kindling, corticolimbic sensitization, and the convergence of affective and sensory symptoms in chronic pain.” Pain Medicine Mar. 1(1): 7-23.

Wallace, Daniel and Clauw, Daniel J. (2005) Fibromyalgia and Other Central Pain Syndromes. Lippincott, Williams & Wilkins. ISBN/ISSN: 9780781752619

References Yunus, Muhammad (2007). Fibromyalgia and Overlapping

Disorders: The Unifying Concept of Central Sensitivity Syndromes. (Biopsychosocial model). Semin Arthritis Rheum. Jun;36(6):339-56. Epub 2007 Mar 13. http://chroniccare.rehab.washington.edu/chronicpain/resources/fibromyalgiaandoverlappingdisorders.pdf

Understanding Pain: What to do about it in less than five minutes? http://www.youtube.com/watch?v=4b8oB757DKc Created by: GP ACCESS by Hunter Urban Medicare Local

National Science Foundation. “How your Brain can control pain.” (MRI examples of focusing on pain http://www.youtube.com/watch?v=oq6YKqSzEUw

References Neuroplasticity made simple 2012

http://www.youtube.com/watch?v=tJ93qXXYRpU

Image of Autonomic Nervous System Organs http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/A/auto nomic.gif

Image of Pain and Panic, Disney © Image of “The Princess and the Pea” Illustrated by Edmund

Dulac, author, Hans Christian Andersen Image of “Notes on Nursing: “What it is and What it is not” by

Florence Nightingale accessed on http://www.abebooks.com/Notes-Nursing-Florence-Nightingale-Dover-Publications/10808136420/bd

Images of neurons, central nervous system, etc. http://brainmind.com/TemporalLobe.htm

Stress & Breathing http://www.npr.org/2010/12/06/131734718/just-breathe-

body-has-a-built-in-stress-reliever http://www.time.com/time/health/article/0,8599,2057269-

2,00.html http://amfix.blogs.cnn.com/2011/02/24/understanding-

chronic-pain/

Thank you for attending.

QUESTIONS?

We acknowledge the financial assistance of the Province of British

Columbia

Contact us:

CIRPD info@cirpd.org www.cirpd.org

PAIN BC info@painbc.ca www.painbc.ca