Can mindfulness help reduce fibromyalgia pain?

With fibromyalgia, affected people feel pain that seems exaggerated or has little to do with an injury or illness. It may make them or other people question if the pain, which can be debilitating and widespread, is all in their head, said Hyannis Rheumatologist Martina Ziegenbein, MD.

“It’s not in their head; It’s real,” she said. “It’s in the brain.”

According to the American College of Rheumatology, research indicates that the heightened pain sensed by people with fibromyalgia results from the operation of their central nervous system – the brain and spinal cord. Studies have shown people with fibromyalgia have several biological reasons that may explain why their pain sensation is heightened, according to the National Fibromyalgia Association. These include:

• Low levels of the neurotransmitter serotonin.
• Raised levels in the spinal cord of Substance P, a neurotransmitter and modulator of pain perception.
• Low blood flow in the thalamus, a portion of the brain that relays sensory information from the body.
• Decreased operation of the HPA axis. The axis consists of the hypothalamus, pituitary and adrenal glands, and regulates response to stress.

The American College of Rheumatology doesn’t consider fibromyalgia an autoimmune disorder or inflammatory disease. However, people with lupus or rheumatoid arthritis, both autoimmune diseases, or osteoarthritis or irritable bowel syndrome, both inflammatory conditions, are more likely to have fibromyalgia, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

People of any age or gender can develop fibromyalgia, but women are twice as likely as men to get it, and most cases are diagnosed in middle age, according to the Center for Disease Control and Prevention. Fibromyalgia often runs in families, so it may have a genetic component, but it’s believed other factors trigger it, according to NIAMS. These factors include diseases that cause pain, as well as having anxiety or depression. Dr. Ziegenbein believes in many cases the central nervous system is reacting to past trauma, perceiving a threat that is not now there.

“Ninety percent of this, I believe, is subconscious,” she said. “There is no fire, no damage, but the alarm, the pain, is real.”

She said blushing when embarrassed or having diarrhea when stressed are examples of how the nervous system reacts and affects bodily functions without our conscious control. Her approach to treating fibromyalgia is to help lower the brain’s reaction to past or present stress.

“Once the nervous system calms down, they do have less pain,” Dr. Ziegenbein said.

A Holistic and Individualized Approach

A mix of medication, exercise and mindfulness can help patients, Dr. Ziegenbein said, who actually has fibromyalgia herself. The federal Food and Drug Administration has approved three drugs for treatment of fibromyalgia: duloxetine (Cymbalta), milnacipran (Savella) and pregabalin (Lyrica). The first two affect levels of the neurotransmitters norepinephrine and serotonin and the third lessens overactive pain signal transmission, according to the American College of Rheumatology.

Some antidepressants and the nerve pain medication gabapentin (Neurontin) also may be prescribed to reduce symptoms, but the college advises that opioids and over-the-counter pain medicines aren’t very effective in directly lowering fibromyalgia pain, though OTC pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil) can reduce pain in the body that’s triggering fibromyalgia pain.

The college maintains that drugs should be used in combination with physical exercise, which it calls the most effective treatment. Dr. Ziegenbein agrees that a combination of approaches tailored to a patient’s specific needs works best.

“Medications are not the answer,” she said. “What works in 50 percent of patients is something else.”

That something else is exercise, mindfulness techniques and other alternative therapies. For exercise, she recommends water aerobics, Tai Chi and yoga. She says alternative therapies of acupuncture, acupressure, journaling and practicing gratefulness can benefit patients.

The American College of Rheumatology recommends cognitive behavioral therapy, as well as stress-reduction techniques using mindfulness meditation.

“My role is teaching and coaching,” Dr. Ziegenbein said.

Brain Exercises

Knowing their pain is in their mind and is not their fault, a sign of weakness or an indicator of new injury or disease, can help many patients. She explains to patients the concept of neuroplasticity – that the brain can form new neural pathways, essentially rewiring how it handles nerve impulses.

Dr. Ziegenbein employs a mindfulness technique called somatic tracking to help patients be in the moment, regard their pain and tell themselves they are safe. She said she instructs patients to think “the (pain) sensation is just a sensation, I’m strong, I’m going to be OK, I’m safe.”

Practicing the technique can allow patients to reduce their dosage of medications, all of which have some side effects, she said.

A small study published last year in JAMA Psychiatry supports use of training patients to change their perspective of their chronic pain as a way of reducing it. Of 151 participants with chronic back pain, 50 received four weeks of training to see their pain as a false signal generated by the brain. The other participants got either a placebo or standard care. At the conclusion, 33 of the 50 patients who underwent psychiatric pain reprocessing therapy were pain-free or nearly pain-free, compared with 10 of 51 in the placebo group and 5 of 50 in the standard care group.

The researchers reported magnetic resonance imaging (MRI) showed reduced brain activity related to pain in the group that underwent psychiatric training. The lead authors are based in Dartmouth College, in Hanover, NH; and Weill Cornell Medical College in New York, NY.

Dr. Ziegenbein emphasized the importance of maintaining a healthy lifestyle and getting enough sleep to keep symptoms manageable. Fatigue and problems sleeping are common complaints of fibromyalgia patients, according to the CDC.

“It’s important to have a tolerable amount of pain in order to function well,” she said.

She endorses the use of marijuana and its psychoactive component, THC, if it helps chronic pain sufferers get off narcotics or just get some sleep.

“Whatever works for you. I have old ladies who eat half or a third of a gummy (cannabis edibles) and sleep well. Why not?”