Integrated Traditional & Western Medicine
Stress Can Be A Pain
Fibromyalgia (FMS) is a chronic pain condition that affects at least 2% of the population. Chronic widespread pain is the defining feature of FMS. Patients also describe a number of nonspecific symptoms such as anxiety, depression, fatigue, unrefreshing sleep, headaches and gastrointestinal complaints such as irritable bowel syndrome. These concomitant symptoms are often exacerbated by exertion, stress, lack of sleep and weather changes. Although there has been a lot of research done on FMS, the mechanisms underlying the causes of pain have not been elucidated, however evidence suggests that various components of the central nervous system (CNS) are involved, including the hypothalamic-pituitary-adrenal (HPA) axis and pain-processing pathways. Sympathetic nervous system (SNS) overactivity within the autonomic nervous system (ANS) is also implicated.
What does the research show?
Research demonstrates the following in patients with FMS:
Evidence of abnormal stress reactivity, including blunting of the HPA and increased ANS responsiveness.
Anxiety, stress and depression are present in 30 to 45% of patients.
Decreased cortisol secretion, suggesting increased sensitivity to glucocorticoid feedback.
Exaggerated noradrenaline (NA) responses as well as delayed Adrenocorticotropic Hormone (ACTH) release, are observed among female FMS patients compared with agematched female controls. Delayed ACTH release in FMS is consistent with a defect in HPA function. Exaggerated NA release may reflect abnormal regulation of the sympathetic nervous system, perhaps secondary to chronically deficient hypothalamic Corticotropic Releasing Factor (CRF).
FMS patients had significantly higher sub-scale scores for somatisation, obsessive-compulsive disorder (OCD), medication used for sleep, and fatigue. 87% of FMS patients reported a stressful event and 42.3% had symptoms indicating post-traumatic stress disorder.
Women with FMS who reported a history of physical or sexual abuse had lower cerebrospinal fluid CRF levels than women who did not report such a history.
The cytokines IL-1, IL-6 and IL-8 are dysregulated in FMS. Therapies directed against these cytokines may be of potential importance in the management of FMS.
HPA and SNS activity
Different stressors elicit different patterns of activation in the HPA and SNS. As Clinicians, we know activation of these systems eventually involves the entire mind/body of the patient. With stressful stimuli the two stress centres of the brain are activated – the hypothalamus and the locus coeruleus (LC). These two components of the nervous system promote a cascade of hormonal, neurotransmitter and cytokine activity that supports our “fight or flight” response. The LC is the master switch for the SNS and stimulates adrenaline and NA production, increasing cardiovascular performance. The hypothalamus signals the pituitary gland, which in turn signals the adrenals to produce cortisol. Normally the cortisol feeds back to the hypothalamus to switch off the stress response and inflammation. However, with chronic unmanaged stress, the body doesn't return to normal and the patient develops progressive heightened neural and neuroendocrine reactivities. Research suggests that chronic stress will eventually result in a hypofunctioning of the HPA, manifesting as low cortisol and impaired ability to shut down the stress response.
Chronic stress causes pain
In addition to these neuro-endocrinological changes, the stress reaction up-regulates the production of inflammatory cytokines such as IL-1, IL-6 and TNF-alpha, as well as increasing cellular oxidation. The presence of these inflammatory and oxidative substances increases pain and fatigue and sleep disturbances. Additionally, with the ongoing stress, substances such as serotonin, that help us deal with pain, are reduced and contribute to further sleep disorders, depression and anxiety. Through other mechanisms, the stress reaction and its downstream effects also impair energy production.
What can we do? In summary, up-regulation of the HPA and SNS, due to stress, results in inflammation, pain, fatigue, depression, anxiety, sleep disturbances and all the concomitant symptoms often described by our FMS patients. It would make a lot of sense then, that prescribing traditional formulae that have a calming effect on the SNS and a regulating effect on the HPA will have long-term benefits for our FMS patients' recovery.
*Reproduced with kind permission from Health World Limited – Australia and New Zealand
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