Episode 10 Fibromyalgia Pain Science Education - Fibro Pain and Neuroplasticity
This episode continues the series on pain science education. When you read about or your doctor mentions that CBT or cognitive behavior therapy can help fibromyalgia symptoms, these episodes cover the foundations of CBT, how your brain copes with stressors, pain, and the think -feel -do cycle.
During the last episode, I talked about automatic thoughts and beliefs and how they influence pain perception and your ability to cope with it.
Today, I was going to talk about the pain-fear cycle, but I realized that there is one topic I have not covered yet, fibro pain, which is essential to understand before we go any further. I want to make sure you understand the terms neuroplasticity and neuroplastic pain.
Neuroplasticity is a general umbrella term that refers to the brain's ability to modify, change, and adapt in structure and function throughout life and response to experience.
Human brains are amazing because of how much they can develop, learn, adapt, and change.
Our brain cells, neurons, can compensate not only for injury and disease but also adjust their activities in response to new situations or to changes in their environment. The brain can reorganize itself by forming new neural connections throughout life; rewire itself.
The brain cells and neurons can make the circuit and network changes resulting from learning a new ability, environmental influences, practice, physical and psychological stress. Like constantly building infrastructure and roads, some roads that are frequently used get upgraded to become a highway, some unused, grow weeds and grass and are forgotten; some are bridges, and some are country roads.
We can use special MRI machines, called functional MRIs, to see the active areas of the brain and how it changes stimulated by experiences. Certain areas of the brain light up on MRI when someone is learning, for example, or in pain.
The human brain is unique and can adapt and learn new things throughout our lives.
But learning, just like learning in school, needs a supportive environment. Like a child who is being bullied in school or comes to school hungry because of poverty, the brain that lacks resources or positive experiences can not learn or adapt as well.
So sleep, nutrition, positive experiences, the reduction in stress, etc., will promote learning and adaptation.
Also, just like us humans, who make mistakes, the brain can also learn wrong things or misinterpret data. For example, if you see a long green, wavy tube moving, you may jump thinking it is a snake, only to recognize later that it is a watering hose.
Some mistakes are easy to correct, some not so much. If you practice something long enough, it will become a habit. Some habits become so automatic we do it without thinking, like brushing our teeth. Or me making my coffee in the morning, I swear, I think I make it half asleep, measuring 4 spoons of coffee on autopilot into my coffee press.
Or, if you drive a car, for example, you turn your blinker on as you turn left or right, without thinking, your brain automatically thinks and directs your hand to turn on the blinker. Or you are driving, and your brain recognizes the red light and directs your foot to press on the car's brake to stop. If you run the red light, the brain will tell you "oh oh", danger, you made a mistake, you can get a ticket.. but our active thinking often ignores routine red lights. We just do it. Red light, stop, green go, left turn, blinker on, etc..
Scientists like to say, "neurons that fire together, wire together. ". If we do something over and over, the brain develops a routine, a route for the neurons to do their job automatically or easier.
So when you drive, the brain cells in charge of your driving, a wired in a circuit – recognizing environment, pushing gas or brake, they all are like a well-oiled machine, know exactly what to do. They fire together because they are wired together after doing the same task over and over. But the brain was not always like that.
If you are just starting to learn how to drive, your brain does not do these things automatically. It forgets to use the blinker. Or you have to consciously think about braking. You can actually watch your thoughts – red light, I need to push the brake, do I have enough time or distance?
If you never drove a car, these circuits in the brain do not exist. But the brain can imagine driving, or can even "pretend" drive a car in a racing video game, but it still takes practice, and if you never played a game, you probably will crash more often than get to the finish line.
The bottom line is – your brain can learn. The neurons that fire or work together get wired together to become efficient and productive. What you practice makes it stronger.
So our brain can also learn bad things. Have you ever had a toddler throw a tantrum? What would the experienced parent tell a mother of a toddler – oh now, ignore the tantrum. If your child learns that tantrums evoke a reaction, attention, the battle is lost, the tantrums will continue... if the 1st tantrum is ignored, that behavior is not reinforced and is likely to never happen again.
So your brain also can learn some tantrums or misbehave, and if the thought, behavior, or something you don't like to keep around was not stopped but practiced, it becomes a bad habit. I am sure we all can attest to numerous habits we have that we are not so proud of having – biting nails, poor eating habits, smoking, using our phones way too much, social media, watching TV too much, etc.
Some habits are formed out of poor coping skills, like nail-biting due to anxiety, overeating for comfort. Some are formed, and we don't even know that they are formed and not serving us well. Like pain.
When your brain experiences pain over and over, the neurons responsible for dealing with pain are wired together. The more pain you have, the better these neurons, brain cells fire together. Just as a driver, the more you drive, the better your foot uses the brake to stop the car.
Basically, your brain can unintentionally learn how to deal with pain incorrectly. The pain gets stuck, like a bad habit.
This pain type, the learned pain, we call neuroplastic pain. Neuro means brain, plastic means adapted, modified, developed. So neuroplastic pain is pain produced when the brain changes in a way that reinforces this pain.
In the last few years, we have had more research in pain science. The functional MRIs of people with new or acute pain produce different images of those with chronic neuroplastic pain.
The acute or new pain from an injury, for example, can be viewed on the MRI in the areas of the brain that processes pain. Neuroplastic pain, on the other hand, shows up in the areas of the brain responsible for learning and memory.
The neuroplastic pain that we see in fibromyalgia and many other chronic pain conditions is different than any other pain. It's different from the pain you would experience from a bone fracture or nerve pain from chronic diabetic neuropathy, or diverticulitis, or appendicitis. The pain that is caused by structural damage is not neuroplastic.
Neuroplastic pain is pain that is remembered by the brain, that is stuck in the memory area of the brain because the brain learned that pain too well; it's a pain that is similar to a habit you formed after a long practice.
The good news is that since we can form habits, good or bad, these habits can be unlearned.
Like a bad habit like smoking or overeating, the pain that was formed by the miswired brain can be unlearned. So in the future episodes, I will teach you how you can rewire your brain to unlearn the neuroplastic pain if you have fibro and other painful conditions.
I bet you have a question about your pain and if your pain is neuroplastic or some other type of pain.
So, if you were diagnosed with fibromyalgia, the fibromyalgia pain is neuroplastic. The IBS-type abdominal pain is also neuroplastic. Some types of headache are neuroplastic pain.
So, when I consult on patients to determine if their pain is neuroplastic or inflammatory, like in rheumatoid arthritis or degenerative like in osteoarthritis, it comes to listening, exam, and pattern recognition. You can listen to episode #2 when I discussed how fibro is diagnosed.
But let's go over what makes fibro pain neuroplastic.
Fibromyalgia onset often starts with stress. Fibro pain often also originates during times of stress. Many of my patients told me that their pain started after a stressful event – car accident, stress at work or divorce, loss of a loved one, severe illness or hospitalization, financial stress. Something put the nervous system in a state of high alert, put under a lot of stress, a situation your brain or body could not cope well.
There is often no apparent trigger or injury. Some patients tell me that they woke up with pain, the pain started out of nowhere, they question themselves, that maybe they injured themselves and just did not feel the injury.
Some neuroplastic pain develops after an injury. Say someone had a fracture due to a car accident. The fracture healed, and time passed, but the pain continued and, with time, started to migrate to other areas. This original pain from the injury became neuroplastic, stuck in the brain inappropriately.
Neuroplastic pain does not cause structural damage, and after years of the pain, there is no evidence on blood work, imaging, or other diagnostic studies of the structural damage from that type of pain. I have had fibro patients for 10 -20 years or longer and have normal workup results.
Neuroplastic pain is the most common type of chronic pain.
Not only fibromyalgia pain can be neuroplastic.
The majority of the chronic back pain, pelvic pain, interstitial cystitis, IBS, headaches are actually neuroplastic pain.
Many treatments are ineffective or provide very temporary relief if the pain is neuroplastic. I have patients who take pain medications, like opiates/narcotics, Ibuprofen type medications, Lyrica/pregabalin, antidepressants, topical rubs, etc., and still are in pain.
Many patients with neuroplastic pain experience significant pain variability – sometimes they have pain, but it can be random, come and go, different severity. A good day will alternate with a bad day, and the symptoms may come on rapidly, like a light switch.
Some things may distract you from feeling the pain. Some people forget about the pain or pain significantly lesson during activities they enjoy – like singing in a choir, church service, football game, or vacation.
But can intensify during the events that are stressful, disliked, or unpleasant – like final exams, presentations, talking to ex-husband, boss you don't like, etc
One of my patients has fibro flares after holidays; she would have nearly no pain during the holiday, she would cook and bake, get her house ready for her kids and grandkids to visit, but once they are gone, she crashes in pain. Her pain is neuroplastic.
Pain is likely to be neuroplastic if you worry about it or think about it all the time. Anticipation of pain, I went to an event on Saturday, on Sunday, I will have a bad day.
Many fibro patients experience many other symptoms along with pain. For example, headaches, body aches, fatigue, abdominal pain, bloating, constipation, feeling like you have the flu… so unless you actually have the flu or some other condition that can explain your symptoms, these symptoms point to fibro. Especially if they come and go, random, come up with stress, and last variable amount of time.
The stress trigger is a common trigger of onset of pain or trigger of flares.
There is a very strong connection to trauma – people who had childhood adversities, trauma, abuse, neglect are more likely to develop chronic pain as adults.
Now, you don't have to have a major trauma to trigger fibromyalgia or other chronic pain; pretty much anything that puts your body in a high alert state, makes you feel unsafe growing up, predisposes to the development of chronic pain.
Some stressors you may not view as stressors now, but as you were growing up, caused a lot of stress on your developing brain – competitive school, bullying, strict religious upbringing, anything that caused a high alert state for your nervous system, fear, anxiety.
Some personality traits are common in patients with fibro and neuroplastic pain. Some of these traits come from the background of trauma, such as people-pleasing, perfectionism, being critical of themselves, being anxious, or worrying a lot. Nervous system sensitivity, likely developed in childhood, is common. Patients tell me that they feel they do not have the reserves to cope with overstimulation, pressures of daily lives, experiences. They also share that they feel drained faster and more often by regular experiences.
Often patients go for years without a diagnosis and may have some progression of symptoms – typically worsening pain, more frequent flares, accumulation of more symptoms with time.
But I want to emphasize again, avoid self-diagnosis see an experienced physician, preferably a board-certified rheumatologist, to have the proper diagnosis.
So let's summarize.
Neuroplasticity is a general umbrella term that refers to the brain's ability to modify, change, and adapt in structure and function throughout life and response to experience. The brain cells and neurons can make the circuit and network changes resulting from learning a new ability, environmental influences, practice, physical and psychological stress.
Brain cells are "neurons that fire together, wire together. ". If we do something over and over, the brain develops a routine, a route for the neurons to do their job automatically or easier. When your brain experiences pain over and over, the neurons responsible for dealing with pain are wired together. The more pain you have, the better these neurons, brain cells fire together.
Your brain can unintentionally learn how to deal with pain incorrectly. The pain gets stuck, like a bad habit.
This pain type, the learned pain, we call neuroplastic pain. Neuro means brain, plastic means adapted, modified, developed. So neuroplastic pain is pain produced when the brain changes in a way that reinforces this pain.
So for homework, think of the time your fibromyalgia symptoms started. Was it during the time of stress? Can you see that your pain is neuroplastic? Do you anticipate pain or other fibro symptoms? Do you have good and bad days? Do you push and crash? Do you feel like your nervous system is often in a high alert state?
So next week, I will cover the pain-fear cycle.
#neuroplasticity, Alan Gordon, Howard Schubiner