Simply being in pain gives your ability to think a hit. The cognitive and pain problems people with fibromyalgia experience appear to be associated with a sluggish autonomic nervous system. Despite being ‘on’ most of the time the autonomic nervous system in FM tends to poop out when faced with stress. That’s unfortunate as reduced ANS functioning during activity and increased ANS activity when resting are both associated with increased pain. The low blood pressure sometimes found in FM can increase pain levels further.
From sleeping, to concentrating on a task, to simply enjoying ourselves, pain has the ability to affect us in so many ways. The origin, though, of the kind of pain ME/CFS/FM patients experience, is still something of a mystery.
We’ve been looking at the role autonomic nervous system problems play in everything from sleep to fatigue in ME/CFS/FM over the past month or so. Now we take a look at two big symptoms – pain and thinking ability – in two fibromyalgia studies and try to figure out what’s causing them.
In the first study Spanish researchers had their FM patients do a math test, assessed their blood pressure, asked them to do a bunch of self report tests and threw everything together…
Slower at the Uptake
People with fibromyalgia didn’t learn quite as fast as healthy controls on one test
People with fibromyalgia took longer to do math tests than the healthy controls. Reduced ‘mental speed’ ‘ may not seem like a big deal but it turns out that rapid information processing is critical to carrying out more complex cognitive tasks. In fact, problems in this critical area are assumed , the authors noted, to be a ‘global indicator of neurobiological damage’.
The fact, on the other hand, that the FM patients were no more error prone than the healthy controls suggested that their particular deficits were in working memory and executive functioning – exactly the same problems found in people with chronic fatigue syndrome (ME/CFS).
‘Learning Potential’ Smacked
Do you have more difficulty learning new tasks? Rather unsettlingly, the tests indicated people with fibromyalgia simply weren’t all that good at learning new tasks. In the 2-minute arithmetic test most people -as they get acquainted with the test – do better during the second minute of the test. The people with FM got a bit better but the healthy controls got alot better, suggesting. as the authors put it, that the FM patients had ‘limited adaptivity to new situations’.
Mood and Anxiety Flame Out (Again) – Pain Scores Big Time
Once again neither anxiety nor depression were associated with cognitive issues. With that horse apparently beaten to death the authors looked around for other causes and found a seemingly obvious one – pain.
Pain was a big contributor to the reduced performance seen on some cognitive tests for people with FM
The degree of pain the FM patients reported was strongly negatively associated with performance on the cognitive test; the less pain a person was in the better they tended to do and vice-versa. Patients on opiates – presumably because of the pain reducing effects – tended to better on the tests than patients not on opiates.
The fact that pain can and will reduce concentration and performance on any task has been demonstrated many times. Studies indicating that pain increases activity in parts of the brain used to carry out tasks (prefrontal cortex, anterior cingulate) suggests what pain sufferers intuitively feel; that people in pain require enormous mental resources simply to screen out pain enough for them to focus on a task.
High levels of pain impair working memory and ‘executive functioning in people with fibromyalgia
In this context it’s interesting that a meditation manual I just saw instructed meditators experiencing severe pain to gather all their mental resources and in effect, stiffen themselves themselves mentally as they focused on that overwhelming stimulus; there’s no playing around with severe pain even for skilled meditators.
The Strange Blood Pressure Connection
Higher blood pressure is usually associated with reduced cognitive performance but this was not true for the people with fibromyalgia. It’s possible that the lower blood pressures found in the FM group meant blood pressure levels never got to the point where their cognitive abilities declined. That would seem to be a plus but it may also point to a problem in their cardiovascular system that not only causes them more pain but places them at increased risk of cardiovascular disease, as well…
That problem was simply a lack of response…..Not only did the FM patients have slightly lowered blood pressure but their cardiovascular response to stress was, in a word, sluggish. Blood pressure should increase slightly as we take on tasks and the heart distributes blood to the areas involved but the FM patients cardiovascular response was sluggish compared to healthy controls, and that, interestingly enough might have everything to do with the pain they feel.
Sluggish Is As Sluggish Does
J Psychosom Res. 2011 Feb;70(2):125-34. doi: 10.1016/j.jpsychores.2010.09.012. Epub 2010 Nov 18. Autonomic cardiovascular control and responses to experimental pain stimulation in fibromyalgia syndrome.Reyes del Paso GA, Garrido S, Pulgar Á, Duschek S.
In the second study these Spanish researchers provoked a pain response and then measured FM patients cardiovascular response to it.
The reduced blood pressure response to stress found in FM is also associated with more pain.
To put it simply the FM patients cardiovascular was underwhelming at best; their stroke volume – the amount of blood pumped out by their hearts, the amount their hearts contracted, their heart rate variability and their cardiac baroreflex response – which maintains blood pressure…were all significantly inhibited relative to the health controls…Their cardiovascular system basically wimped out.
They displayed a strange pattern we’ve seen before; although their sympathetic nervous system was always ‘on’, putting it under stress caused it to poop out. This suggested the ANS is the source of the ‘wired but tired’ problem; it can’t disengage and then flops when it’s asked to respond.
A Central Response System Blunted
A key system controlling FM patients blood pressure appears to be under particular stress in FM. The baroreflex response keeps our blood pressure under control by controlling our heart rate; if our blood pressure rises too high, it tells the brain to slow our heart rate down. The brain then tells the autonomic nervous system to do that. If our blood pressure drops too low it does the opposite.
The cardiovascular systems of people with fibromyalgia responded poorly to ‘stress’
(It does this using receptors called mechanoreceptors (eg baroreceptors) that line our blood vessels. If our blood pressure rises too high the mechanoreceptors stretch and, in doing so, send a signal to the brain to slow our heart rate down. If they’re not stretched at all (ie if you have ‘loopy’ blood vessels :)) they signal the sympathetic nervous system to become activated).
The FM patients baroreceptor response (baroreflex sensitivity) was muted. A similar problem seems to be occurring in chronic fatigue syndrome (ME/CFS). A recent study by the Newton Group indicated systolic blood pressure was muted when ME/CFS patients stood up. Reaching further back Peckerman found reduced baroreflex sensitivity in 2001 and 2003 in both Gulf War Syndrome and ME/CFS patients.
This study indicates that CFS alters baroreceptor reflex functioning..(and was) accentuated in the patients with severe CFS….Arnold Peckerman (2003).
System Burnout
Is the autonomic nervous system too burnt out to respond well to stress? Some studies suggest it is…
Wyller’s finding of reduced systolic blood pressure variability upon standing in ME/CFS and increased sympathetic nervous system activation suggested to him that the stress response system was approaching burnout and he proposed that it might collapse (ie not respond) under more severe stressors than standing.
(Such as exercise?…Is the ‘collapse’ in the ability to produce energy some ME/CFS patients demonstrate when they undergo a second-day of exercise testing the result of sympathetic nervous system ‘collapse’ ?)
The Pain of it All
Of all the autonomic measures tested, one – the baroreflex sensitivity (the ability to modulate blood pressure in response to stress) was highly associated with pain in the FM patients. That is, FM patients with more pain were less able to alter their blood pressure in response to stress than were patients with less pain.
As an added bonus, the more ‘adjustments’ ones baroreceptor’s made over time; ie the more active their baroreceptors were, the more tolerant of pain that individual was. The more sluggish the autonomic nervous system was the more likely that person was going to be in pain.
A reduced ability to regulate blood pressure in fibromyalgia appears to be associated with increased pain
What’s going on here? How could problems in the cardiovascular system be associated with more pain? In fact the relationship between increased baroreflex sensitivity and reduced pain and between low blood pressure and increased pain is well known. If you have lower blood pressure or if your cardiovascular system just does not respond to stress well, it’s likely you’re going to be in more pain.
It gets worse. Central sensitization and chronic pain are also associated with increased resting blood pressure -which can be found in both ME/CFS and fibromyalgia. If you have the weird combination of increased resting blood pressure/heart rate but a sluggish blood pressure response to stress; ie if you have the wired but tired syndrome found in ME/CFS/FM you’re on track for more pain…
The significant role the autonomic nervous system plays in pain production in FM/ME/CFS suggests getting it under control could be very helpful.
The Cause?
Nobody knows what’s causing this but some attention has been drawn to the ‘rostroventral medulla’ in the deep brain which controls both hypersensitivity to touch and temperature and the baroreflex response. Some researchers believe constant pain signals from the body cause neurons to grow that somehow intermix both pain and cardiovascular signals.
Let’s end this on the happy note that lower baroreflex responsiveness is associated with increased risk of cardiovascular events (eg. heart attack and stroke). Several studies suggest people with ME/CFS have indices associated with increased cardiovascular risk.
Conclusions
Simply being in pain gives your ability to think a hit. The cognitive and pain problems people with fibromyalgia experience appear to be associated with a sluggish autonomic nervous system.
Despite being ‘on’ most of the time the autonomic nervous system in FM tends to poop out when faced with stress. That’s unfortunate as reduced ANS functioning during activity and increased ANS activity when resting are both associated with increased pain. The low blood pressure sometimes found in FM can increase pain levels further.
Constant pain signals from the body that cause neurons to mistakenly intermix signals could be contributing to the pain, cognitive and autonomic nervous system problems in ME/CFS/FM.
Pain unfortunately is another nebulous term like “fatigue”. What does this mean exactly? I have stiffness/body rigidity and what feels like inflammation. Is this pain? I don’t think so but MDs do because they translate that into “pain” but I disagree.
I like the term “sluggish”. This is not exactly an endearing or ideal term either but I think it is a bit more descriptive and one that I’ve used myself.
The best answer at the moment is in the 2 day exercise test. Until disproven there seems to be evidence of perverse dysfunction preventing people from functioning properly after an initial exercise “stress test”. No questionnaires, just objective proof that the body is not functioning properly.
I found it extremely discouraging Unger is looking to scuttle this and make it a one day test. I have not seen any evidence that the one day test is enough to distinguish the phenomenon. It’s also discouraging Unger thinks the CCC is too complex for MDs.
After listening to CFSAC I agree on the 2-day test. I wonder if its more of a logistical problem with most of the docs not giving it to their patients anyway. I have the feeling that the CDC isn’t paying for any tests – they’re simply tracking the data the doctors take down but I wish they could include it
I definitely have stiffness/rigidity particularly after exercise and pain….It feels like my muscles are burning. If I really exercise too much almost every movement feels painful.
See you’re catching on! I think that it’s at least a start. Specifically where is the “pain”, when does it occur, what “hurts” and for how long. I still maintain it’s problematic though because it’s still a subjective measurement. People’s perceptions can vary tremendously on what constitutes “pain”.
The CDC should make it clear what the problem is. This is the closest to the gold standard that we have at the moment and Unger is fundamentally blowing it off by only doing the one day. I am not sure if it’s really clear what is going on but I think that is the point: it’s important enough to understand what the thought process is.
I’d like to know if it’s a “logistical”/cost issue or whether they dispute the “science” behind it.
I just talked to Staci Stevens…The CDC is paying for the testing…its up to them whether they will go for the 2-day test or not. The CDC contracted with Dr. Kogelnik….Staci has recommended to Dr. Kogelnik that the CDC do the 2 day test. We’ll see what happens but its entirely up to the CDC.
Staci is emphatic that 2-day test will give so much more information and she has recommended a type of 1-day test as well. (For one thing only by using the 2-day can she wipe out the deconditioning theory since she’s found that deconditioned healthy controls do not drop on the second test.)
Thanks for the update. I appreciate it. Staci’s comments align with what I thought was the case: the 1 day test isn’t distinctive enough. Any abnormality will just assumed to be the result of deconditioning.
I have been having the pain the commentators are describing along with sciatica that occurs if I am active (walking). If I keep moving the pain is low, the second i stop moving or sit, sciatica goes into crazy mode and pain is hardly bearable (can’t keep from grimacing or crying out in pain). Also my PEM doesn’t significantly hit til day 2. Depending on how much I pushed myself the previous days (take a shower, and sedately attend at party for 2 hours), I could not even talk intelligibly or form thoughts in response to questions. My body feels almost frozen from exhaustion and can barely turn over in bed when my joints hurt too much. And barely open my eyes. Not every PEM is as severe, but I never know what will happen. A definite worsening of PEMs after 24 years with this disease. Docs put me on anti-migraine meds, opiates, but my drowsiness is so debilitating I still can’t function. The low doses just mess with me. Could feel I had energy, could think and speak decent, but couldn’t keep my eyes open. Not very helpful, especially if the pain is only reduced to the nagging level. (Bad response to Topamax… Couldn’t hardly breath, bad heart flips, etc… Investigated and found it works on the glutamate responses of the nervous system. … Which is one of the areas being researched for CFS. I just hope help will come soon. I have two young kids I am surviving for… 🙂
I’m the same way with day 2 PEM and I get the frozen feeling; for me it’s really like stiff person syndrome…I get all stiff – although I’m not nearly as bad as you.
Hang in there Tracey! I have a blog coming up on a woman who improved mightily using Staci’s methods…Maybe it will help..
Oh, forgot to mention…. can the subjectiveness of pain be equalized by the dysfunction it causes?
Nice article, fits quite nicely with my own understanding of these disorders vs. central sensitisation and blood flow abnormalities, as per my conceptual model:
http://johnhwolfe.wordpress.com/me-cfs-cfids-aetiology-pathophysiology-wolfe-hypothesis
I wonder what you make of this hypothesis?
I must have a good look through some of the articles you cite as I’m sure they will help me flesh out the concepts a little more e.g. Chung on afferent input from nerves vs. ‘Wind up’ (central sensitisation), ties in very nicely 🙂
Thanks John,
Hey, that’s the best summary of ME/CFS research I’ve ever seen :)…
How are you doing after following your protocol?
Hi Cort,
Thanks for your response, that’s kind of you to say, I’m glad you like the summary 🙂
Without wishing to bore you with too detailed a case history, perhaps a little context is important to give you an accurate impression. I’ve been receiving Perrin Technique manual lymphatic drainage for just over a year, and started pursuing dietary interventions e.g. my leaky gut protocol, around the time I started to put the ME/CFS wellness protocol together last autumn
The combined impact of these measures hit me pretty hard in terms of illness and weight loss and I only started to ease up on both in the New Year. It is only in the past month or so that I have been willing and felt able to return to research in a meaningful way, and it is only in the last week or two really that I have come to realise just what a significant role physical and behavioural factors (such as posture) may play (in the light of Rowe’s ongoing study)
Against this background, only very recently have I felt it possible to gauge the impact of D-Ribose/Thyroid support formula and I have yet to finish making the necessary arrangements on the postural/seating front – although I have been avoiding hip flexion except for during my stretch routine. I should also note that I have yet to incorporate some of the suggestions in my protocol into my personal regime
So it is early days but, so far, in spite of inadequate rest over the past few weeks (thanks primarily to this research!) the signs are encouraging – my sleep has improved (thanks primarily to managing my nocturnal water retention more diligently, plus postural and respiratory discipline) and I have had a few days where I “felt almost like the old me” in terms of mental energy and functioning (thanks presumably to things like D-Ribose supplementation, plus postural and respiratory discipline)
Glad to hear it John. I’d love to talk more…
Sure thing, feel free to drop me an email
Good job.
Thanks
Great info! When I was in the ER last week, my heart rate was 42 and BP was very low. Lower than normal. And I was in severe pain. I’ve never heard that explanation before! Thanks!
Me either…I was really surprised at the effects cardiovascular problems can have..Who knew?
I don’t think we are less smart due to pain and bloodflow issues, the key is the timing of it. Attempting to do cognitive work sitting upright at a table is defeat. Sitting in a chair with an ottoman helps, getting the knees level with the heart is a solution for me. My sympathies to others dealing with sciatica, and I found the medication Diclonefac very effective (brand name Voltaren). Feeling my heart rate shoot up while standing in line, I automatically squat down to look at products on the lower shelf or tying my shoes stops ‘brain drain’. There are ways to ‘compensate’ by changing bodily position, some are employed without much thinking at this point. Found easy yoga helpful, but cannot do the ‘downward facing dog’ as the head is lower than the heart, and I shake, excessive heart rate… I continue to read and challenge my brain with certain crosswords, research, and free courses on-line, find I am a bit slower but I am not doing things like this, under pressure, etc. I truly feel the symptoms of dysautomia are exhibiting a reflex, meant to protect our hearts and brain. But I do not engage in high aerobic exercise, that is asking for a crash. It was evident at the YMCA pool that I could no longer swim as I used to, and was very weak from just a bit of water walking, and was confused when I was done, throwing my keys into the gym bag, shutting the trunk was a perfect example of how much I had changed, sadly. Also, standing in water causes the lymph nodes to be compressed, and I was ill from the fluid re-entering the bloodstream. Be careful in public pools, as to bacteria and contaminants in the water, and take a friend!
Interesting post, have you investigated OI, and treatment options? In case you haven’t already considered this I understand high quality, tight fit compression garments can ease orthostatic stress in certain patients e.g. should help prevent you feeling like you need to crouch down so much when shopping (now I know why I remained so keen to ride in the shopping trolley as a child (don’t you just love how ME/CFS gives you so many retrospective excuses for childhood quirks!?) 🙂
You’re right, those who have OI (the vast majority of ME/CFS patients) do benefit from the supine/recumbent position in terms of cognitive functioning, but I believe there are other mechanisms inducing cognitive deficit (particularly because in the past I have twice been in remission and recovered normal orthostatic tolerance, yet the final 10-20% of missing ‘mental sharpness’ still eluded me)
For me, the enhanced post-exertional malaise ~ ‘brain fog’ we often experience cannot be explained by general fatigue, acidosis, or orthostatic stress; noxious/neurogenic stimulation (impacting on a dysfunctional sympathetic nervous system) and mitochondrial energy dysfunction would explain the enhanced, and lingering, confusion and apparent lack of ‘mental energy’ respectively
The only type of swimming I’ve been advised to do/advise others to do is ‘sculling’ – preferably with a float for your feet – you might try this. It’s the least stressful for the body in terms of exertion and OI, and the motion of the skeletal muscle/shoulder blades is like a natural lymphatic pump, particularly when combined with full range diaphragmatic breathing (yes, expect some illness if you have yet to address lymph backlog but dealing with lymphatic drainage dysfunction is necessarily in order to maximise chances of recovery in my view)
Yes, I do too; thanks!
I have recently done quite a bit of reading regarding CFS particularly, however it relates to Fibromyalgia directly. It seems by improving nerve cell health and cellular metabolic function you can combat these ailments at their cause. Improving cellular energy production and reducing free radicals through many natural supplements available on the market.
The one thing that caught me off guard when doing my research, was just how prevalent these issues are among people today. Often times going undiagnosed.
Interesting article. I am 45 have had fm since age of 12 and recently received a pacemaker. Electrocardiologist says his theory is it relates to auto immune disorder. So this article is so on point with
It sounds like you have an good (and unusual) electrocardiologist. Good luck with everything.