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 We acknowledge the financial assistance of the Province of British Columbia

CIRB2012

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

Poor Sleep Physical Trauma Peripheral Nociception

Genetic Predisposition

Hyper-excitement of Central Neurons

Psychological Factors – Stress Neonatal or Childhood Trauma

Infections Inflammation

Other Factors

ANS Dysfunction

Central Sensitization

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

Environmental Noise Chemicals Others

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

Effects of Chronic Stress

S Breaking Point S Stress Level Response

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S S S

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P P P

P P

P

P P

P Time

S S

S

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S= Sympathetic P= Parasympathetic

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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 Fatigue Interstitial Cystitis Irritable Bowel Syndrome

Fibromyalgia Myofascial Pain

Depression PTSD

Central Sensitivity Syndromes

Migraines Tension Headaches

TMJ

Restless Leg Syndrome

Chronic Pain Problems

Multiple Chemical Sensitivities Postural Orthostatic Tachycardic Syndrome

Modified from Yunus 2007

How You Feel Acute Pain Pain source Electrical impulse moves through nerves to the spinal cord Nerve cells in spinal cord release chemicals to amplify or subdue pain message Brain interprets the message as pain (Mayo Clinic on Chronic Pain)

How You Feel Chronic Pain Chronic condition, injury or unknown Nerve(s) sometimes misfire and send wrong messages Possible chemical imbalances that affect pain response Brain interprets the message as pain (Mayo Clinic on Chronic Pain)

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.htm l

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 Sleep Hygiene

Positive Thinking

Communication

Decrease Symptom Focus Relaxation

Socialization

Stress Management

Humor

Moderation

Leisure/Fun

Time Management Spirituality Exercise

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

 Dampeners – – – – – – – – –

Relaxation Regular exercise Good sleep hygiene Decreasing perfectionism Positive outlook Humor Balanced nutrition Healthy boundaries Meaningful free time activities

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 Pain and Panic from Disney ©



Can also be “unlearned”

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

*Neutral*

•Overly caretaking •Asking about pain •Take on more responsibility •“pillow fluffers”

Punitive •Try to help but can’t

•Not asking about the pain

•Frustrated

•Diversion or Distraction (redirect focus)

•Guilty

•Angry/Resentful

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 Sleep Hygiene

Positive Thinking

Communication

Decrease Symptom Focus Relaxation

Socialization

Stress Management

Humor

Moderation

Leisure/Fun

Time Management Spirituality Exercise

Nutrition 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/fibromyalgiaand overlappingdisorders.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-NightingaleDover-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-breathebody-has-a-built-in-stress-reliever  http://www.time.com/time/health/article/0,8599,20572692,00.html  http://amfix.blogs.cnn.com/2011/02/24/understandingchronic-pain/

Thank you for attending.

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We acknowledge the financial assistance of the Province of British Columbia

CIRPD [email protected] www.cirpd.org PAIN BC [email protected] www.painbc.ca