Posts

Rheumatoid Arthritis and Fibromyalgia

Why Does Fibromyalgia Occur in Rheamatoid Arthritis – a Neurological Perspective

Rheumatoid Arthritis and Fibromyalgia

When working with a large number of patients with chronic pain and illness, you begin to notice patterns in relationship to certain illnesses. One of the more common trends I see today is the association between having an inflammatory illness like rheumatoid arthritis along with widespread body pain like fibromyalgia.

Rhumatoid arthritis and fibromyalgia share some commonalities in that they disproportionately affect women more than men, are associated with flare ups of increased pain intensity, and are chronic illnesses with no cure. Although they are separate and distinct health issues, it seems that if you have an inflammatory illness like rhematoid arthritis, 10-15% of these patients are likely to report the widespread body pain of fibromyalgia. Let’s see if we can break this phenomenon down.

Rheumatoid Arthritis and Inflammatory Illnesses

Rheumatoid arthritis falls into a class of inflammatory disorders where flare ups of inflammation can create damage to joints throughout the body. The pain from these flare ups can be debilitating, and the damage done to the joints can be quite severe when left untreated.

CanStock Photo

Notice the deformity of the thumb and index finger on the right hand. CanStock Photo

The damage to these joints is caused by an autoimmune reaction. Autoimmune disease is a condition where the body’s own defenses inadvertently create harm to the body itself. In the case of rheumatoid arthritis antibodies can build up in the joint spaces and cause other immune cells to create an inflammatory reaction in the area. This is where people can feel the heat, swelling, and pain that is known to occur in flare ups.

Patients with rheumatoid arthritis tend to have arthritic flare ups affect joints like the hands, toes, and neck. However, they are also more prone to wide spread pain in other regions not associated with arthritic breakdown. Why would pain exist in an area that is not associated with inflammation and destruction of the joint?

Chronic Pain: Central  Mechanisms

Pain is an extremely complex phenomenon. We generally think of pain having a direct relationship to tissue damage. When we get a cut, sprain an ankle, or break a bone we expect that pain will occur because of the injury. Therefore it’s not surprising that the pain and destruction from a rheumatoid arthritis attack to be very painful.

However, we also know that pain can occur long after an injury has healed, and even in the absence of injury whatsoever. This is what happens in patients with the widespread pain of fibromyalgia. People with fibromyalgia often have nothing to point to as a cause of their pain. It’s an enigma that makes chronic pain syndromes so frustrating because they have no test or image to prove why they feel so poorly.

Many suspect that this widespread body pain may be from dysfunction at the level of the central nervous system. In normal circumstances, the brain has a few ways of controlling how much pain it will feel.  This ensures that our bodies don’t overreact to normal everyday stimuli and interpret as painful.

One mechanism is by pain inhibition. Pain inhibition involves the brain using it’s own pharmacy of pain killing chemicals to stop a pain signal from going up the spinal cord.

Pain can be inhibited by chemical pathways inherent in the brain.

Studies on patients with rheumatoid arthritis have shown that the brain’s ability to inhibit pain becomes compromised leading to an increase in pain with normal stimulation. [Source]

Pain Inhibition broken

When your brain has difficulty inhibiting pain, then you begin to feel it in places where there’s no injury

Another way that the brain can modulate pain is through a concept known as the pain gate. The pain gate operates on the idea that pain has to hit a certain threshold for it to be consciously perceived in the brain. In this way, it allows the brain to ignore things that aren’t causing much damage or risk.

In a perfect system, you would only feel pain when you have actually created injury or are under imminent threat of injury. However, this appears to be another mechanism that gets disrupted in chronic pain patients. When people have chronic pain, it probably means that the gate that is meant to block most of your pain is letting everything in.

Pain Gate Theory

 Does Rheumatoid Arthritis Break This System Down?

The main treatment for inflammatory arthritis focuses on managing inflammation. Most patients with this type of arthritis will take a wide variety of anti-inflammatories that cover a wide spectrum. They include drugs that specifically target the inflammation associated with RA like Trexall, immune modifying biologics like Humira, and go all the way down to non-steroidal anti-inflammatories like ibuprofen.

In many of these cases, the inflammatory pain of arthritis is under control by these drugs, yet the widespread body pain persists. We don’t really know how or why these inflammatory disorders can lead to pain sensitization, but studying other acute pain conditions may give us some clues.

Studies done on patients with acute pain from a traumatic injury and post-surgery pain issues. When someone suffers from the pain of a major injury, the neurons associated with the pain response start to fire more frequently to guard against the area of injury. This is only supposed to be a short term response to significant injury, but in some cases these changes become persist through a phenomenon known as plasticity. When these spinal cord neurons stay hypersensitive, it means that a person’s nervous system will become hypersensitive to the pain response. [Source]

While inflammatory arthritis isn’t necessarily an injury in the classic terms, make no mistake that inflammation can create a significant amount of tissue damage when it goes unchecked.

Making Your Nervous System Less Sensitive

If the nervous system can be made more sensitive by persistent pain, can it work in the opposite direction? A lot of the research on pain has been focused on targeting these mechanisms which has lead to a higher usage of opioid medications. The obvious problem is that opioids are highly addictive and has become a major public health issue.

There is a growing need for non-pharmacologic interventions to address these chronic pain issues, and fortunately there are some that can be really effective. In cases of chronic pain, the best approach is one that addresses a person from a mental and physical standpoint rather than chasing after a holy grail treatment.

When you look at the pain gate theory image, you can see that the factors that impact your pain threshold include brain and spinal input which exercise and chiropractic adjustments can play a major role. Things like memories, emotions, expectations, and attention are all factors that can be changed with neuropsychological therapy. Out of that entire list, everything except your genes are modifiable factors.

Our approach to chiropractic is focused on the head and neck, which has been shown in at least one study to improve long term outcomes in patients with fibromyalgia syndrome when combined with exercise and cognitive based therapy. You can read more about that in a previous article below:

Fibromyalgia and the Atlas

Conclusion

At the end of the day, there is no cures for rheumatoid arthritis or fibromyalgia yet. There may not be cures for years to come. However, many people with these illnesses can see their quality of life improve by addressing some of the neurological consequences of the disease.

Ask Dr. Chung a Question

Medication Overuse Headaches

Combating Medication Overuse Headaches

Medication Overuse Headaches

Medication overuse headache (MOH) is a very common manifestation of chronic headache patients. It is one of the unique instances where a once effective way of controlling an illness will actually perpetuate the illness further as the body adapts to a chemical intervention. This condition is unique to patients with chronic daily headache disorders and various chronic pain syndromes like fibromyalgia.

The most frustrating part about MOH is that you may do better for a long period of time because of a medication, but as the effectiveness of the medication wanes over time you may actually experience the headache worse than before.

It’s a situation that can cause despair as medications are generally the treatment of choice for all headache conditions. If your body has become resistant to all of the available medications, what can you do next?

Why Is Your Medicine Making Your Head Hurt?

People with chronic headaches will generally have 7-10  headache days per month. For better or for worse, there are a wide variety of medications that can help knock a headache out or prevent them from occurring. It’s not unusual for a chronic headache patient to have  a cocktail of drugs that they have to take on a daily basis.

The problem with a frequent medication regiment in chronic pain conditions is that the cells of your body almost always have an adaptation to to make itself more resistant to the medications’ effects. This can happen even if you’re taking your medications correctly as prescribed by your doctor.

The headache that results from MOH is often called a rebound headache. As the effect of the medication wears off, the headache returns rapidly which can create a need for another dose of medication. In this way it becomes a cycle of struggle as the effects of the medication start to decline faster and the rebound headaches become more persistent. When this occurs, the chronic headache patient can become the chronic daily headache as the headaches will begin to occur greater than 15 days per month. Because of the reliance on these medications, medication overuse headache has become the 3rd most common headache disorder, and the most common cause of migraine-like symptoms.

Research has shown that this can occur regardless of the type of medication you take. It’smost frequently associated with prescription migraine medications, but it has been documented to occur in people taking over-the-counter drugs like ibuprofen. Hard pain meds like oxycontin may be used by headache patients without a doctor’s prescription, and these can tend to accelerate the process to MOH because of the way that opiods sensitize your brain.

You can read more about how pain pills can make your pain worse in this article I wrote last year:

Research: Can Pain Pills Cause More Pain Over Time?

How to Beat Medication Overuse Headaches

The easy answer is to stop taking your medications for a while because….

you can't if you dont

If you don’t understand this meme, then ask someone who is younger than 30. I promise it’s funny.

Unfortunately, biology isn’t that simple, especially if you have chronic pain.  Are there side effects to stopping a daily medication? Will you experience worse pain when you stop taking the drugs? How will you cope with the pain if you can’t take any meds? How long will this take before you can make the meds work again?

Chronic headache patients need effective non-pharmacological methods to deal with the pain of headache physiology.

One specific target for drug-less treatment of headaches is by correcting dysfunctions in the neck.

In many cases, headaches syndromes can be a result of a secondary effect of a shift in at the top of the neck. This is why chronic headache patients are some of my favorite people to see in practice because a gentle correction of the neck  has allowed us to have a very high success rate with chronic headache syndromes.

While addressing the cervical spine may not address the cause of  a medication overuse headache, it may help fix the primary source of a patient’s headache condition so that taking the medication becomes less necessary. The most common comment I get from headache patients is when they tell me that they’re taking less ibuprofen since they started getting their neck better.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

Within 2 weeks of neck corrections with the NUCCA procedure, the vast majority of our headache patients experience relief in either the frequency or intensity of their daily headaches.

Not All Neck Adjustments Involve Cracking

A lot of people are scared about having their neck worked on by a chiropractor. The general portrayal of a neck adjustment by viral Youtube videos can make it seem scary.

While chiropractic adjustments have a tremendous track record for safety, the bottom line is that a lot of people just don’t want their neck cracked because the sound and the motion make them really uneasy. This leads to patients tightening up their neck and bracing which can make a neck manipulation hurt in the hands of a chiropractor that is not skilled.

That’s one of the big reasons why I’ve used the NUCCA procedure throughout my career. The NUCCA procedure involves a very light pressure to correct the neck as opposed to a high velocity manipulation. By using the NUCCA procedure, the doctor is able to measure and control how much force goes into the neck, and if we have corrected the underlying dysfunction. All of this happens without the popping, twisting, or cracking of the spine.

Not all patients with headaches are good candidates for the NUCCA procedure. Only patients with a subtle shift in the top vertebra called the Atlas will benefit from the NUCCA correction. A thorough history and examination will help us determine if the Atlas is causing a problem and if it’s something that can be fixed.

 

Request a Consultation with Dr. Chung

trigeminal neuralgia

Unraveling Trigeminal Neuralgia

trigeminal neuralgia

[8 minutes]

Unraveling Trigeminal Neuralgia

​Most of you have probably never heard of trigeminal neuralgia (TN). It’s a pretty rare disorder that affects about 4-5 people per 100,000. If you or someone you love has ever had it, then you know that this illness can be associated with the worst pain that a human being can experience. The constant and persistant pain is so debilitating that TN has been called “suicide disease” because an estimated 25% of sufferers will take their own life.

​Today we are going to breakdown the anatomy of this devastating disorder, and how we can help.

​The Anatomy of Facial Pain

Trigeminal neuralgia can seem very simple on the surface. The name of the disease stems from the nerve that it attacks called the trigeminal nerve. The trigeminal nerve is one of twelve specialized nerves that come from inside the skull called cranial nerves. As the trigeminal nerve exits the brainstem, it sends branches all throughout the head and neck. Here is a short list of the things connected to the trigeminal nerve:

  • ​Sensation on the surface of the head and neck (especially pain sensation)
  • Sensation in the teeth and gums
  • The meninges
  • Major jaw muscles

​You can see how the nerve spreads and some of its major branches here:

The Trigeminal Nerve

The three main branches of the trigeminal nerve are the opthalmic branch (v1), maxillary branch (v2), and the mandibular branch (v3).

​While trigeminal neuralgia is a very specific illness with a set diagnostic criteria, the cells that form the trigeminal nerve have been implicated in pain issues that include migraine headache and jaw pain (TMD). This is because there is a bundle of cells in your spinal cord that act as a relay station for all pain perception in the head and neck called the trigeminal cervical nucleus.

In the most simple terms, if you were to go to a dentist and had your gums poked, it would fire a receptor called a nociceptor. This nociceptor travels through the trigeminal nerve, into the spinal cord, and up into the brain where it perceives that signal as pain.

Using this idea, scientists have tried to identify lesions along the trigeminal nerve in people with trigeminal neuralgia that consistently set off the pain response. It’s been suspected that an artery near the brainstem can pulse and compress the trigeminal nerve roots. These pulsations explain why patients can feel waves of shock like pain, with brief moments of relief in between.

There is also evidence to suggest that inflammation or trauma in the brain or spinal cord can make the brain more sensitive to the pain response. This is known as central sensitization.

It’s important to know this because knowing if the problem is from a peripheral lesion like an artery warrants a much different treatment than a condition where the pain is mediated from a central location.

Treatment Options

Peripheral Lesions

Most cases of true TN are resistant to anti-inflammatory medications.  When anti-inflammatories fail, they are treated with anti-convulsant medications like Tegretol or Neurontin. These medications can be effective for some, many patients find the side effects (dizziness, brain fog, balance problems) of these medications to be intolerable.

For patients with a peripheral lesion like artery or vein compression, there are surgical options. If patients have a confirmed compression of the trigeminal nerve roots by an artery, a surgery called micovascular decompression can be used to move the offending artery off of the nerve. The surgery has a very high success rate for a large number of TN cases, but it is also is a major surgery which requires cutting through the skull, and has risks that come with neurosurgical procedures.

Other procedures like Gamma Knife radiation can be performed to damage the trigeminal nerve so that it does not transmit the pain signal to the brain. This procedure has been less effective than decompression, and also may require additional procedures.

While these procedures can be great options for TN as a result of a displaced artery, it is unlikely to help those whose symptoms are not part of the peripheral nerve. Some forms of TN may be a brain related issue.

Central Disruption – A Brain Processing Problem

Problems in the peripheral nerve structure are easy to understand. You have delicate nerve tissue that hates to be compressed and you have an offending structure that is rubbing or compressing the nerve roots. When you remove the offending structure, then the nerve problem goes away. In a way, a peripheral lesion is similar to the way that a herniated disc causes the pain from a pinched nerve.

But what if you have this face pain but there’s no sign of a rogue artery pressing against the nerve? The problem may be with processing of pain rather than an offending lesion.

While peripheral problems are easy to understand, central problems can seem more abstract. When the brain and spinal cord aren’t working properly, you can’t do a blood test or look at an MRI and definitively say “This is why you have pain in your face”. In order to test this idea, you often have to perform functional tests which test how your body feels different stimuli.

Central disruption is more of a problem of too much or too little.

What I mean by that is that neurons in the brain can fire too often while other important nerves may not fire enough. When the firing of these nerves is out of balance, then the brain perceives things incorrectly.

Pain experienced in the head and neck can be dictated anywhere along these pathways

Pain experienced in the head and neck can be dictated anywhere along these pathways

The pain pathways of the head and neck converge into an area of the spinal cord called the trigeminal cervical nucleus. So if you have a pain in the head, face, or neck, all of the pain sensing fibers are going to enter into this region which is found in the spinal cord around the level of the first 3 neck vertebrae.

Our perception of pain is dictated by the multiple factors that include the current environment, memory of past pain, genetics, expectations, and our attention. The trigeminal cervical nucleus, thalamus, and somatosensory cortex have a system determining if the brain should pay attention to a painful stimulus. This is what allows people to feel pain differently.

That’s why  our favorite athlete can ignore the pain of a broken leg in order to complete a task. It also allows us to perceive danger if we step on a nail in the dark.

When this system malfunctions, then the trigeminal cervical nucleus is allowing too many pain signals to get through to the brain. When it allows every painful stimulus to get to the brain, then the brain is constantly bombarded with pain signals even if that signal is harmless.

Symptoms of facial pain can be a result of too much firing from the trigeminal cervical nucleus.

That’s what allows a cool breeze to the face, brushing your teeth, or scratching an itch on your face can be wrongly perceived as a painful stimulus that sends them cascading toward miserable facial pain.

When it comes down to it; your brain is perceiving the environment incorrectly because it is letting too much pain stimuli through the pain gate.

This is the cornerstone of the Gate Theory of Pain below.

Pain Gate Theory

 

The good news about a central pain response is that your pain threshold can be changed by several factors as listed in the diagram. While we can’t change our genetics, we can change almost every other factor on that list. From a treatment perspective, there are numerous things we can do to change brain and spinal cord input so that pain output decreases.

Fixing the Neck to Fix the Brain

Chiropractors that focus on the upper neck have found a large amount of success in helping patients with trigeminal neuralgia and other facial pain syndromes. A quick search through chiropractic literature shows a dozen case studies detailing the improvements of patients with facial pain syndromes (including my own here if you want to read it link here).

Obviously these are just case studies and can’t tell you much in themselves(I’ll save my rant on the politics of chiropractic research later. How is there not a formal study on trigeminal nerve issues and chiropractic by now?), but there is a logical rationale that helps explain how the neck can affect facial pain and why 75% of our trigeminal neuralgia patients get substantial improvement.

Let’s look at that graphic and highlight some important components:

Pain Gate Theory

 

Brain input and spinal cord input play a big role in the sensation of pain. A big part of brain and spinal cord input comes from the top 3 nerves in the neck.

When the head and neck shift, brain and spinal cord input get altered in ways that can impact the trigeminal cervical nucleus. In our office, we find that this is particularly common when the Atlas vertebra rotates or twists out of position.

Atlas Rotation

When this shifting occurs 3 things happen:

  1. Torsional forces occur in the spinal cord potentially impacting the trigeminal cervical nucleus
  2. Compressive forces may occur along the vessels that can affect movement of spinal fluid and blood in the head.
  3. Aberrent input into the brain from asymmetry of spinal positioning leading to dominance of nociception (pain) into the brain.

When the neck shifts in this manner, it doesn’t always cause trigeminal nerve issues, but it is tied to other problems like headaches, neck pain, cervicogenic vertigo, and more.

It brings us back to a fundamental principle: upper cervical chiropractic is not about treating a specific condition. It’s about improving the function of the brain and nervous system.

When we correct the structure of the neck, we are looking to decrease these damaging forces into the spinal cord and veins and improve the symmetry of firing into the brain.

The atlas on the left is almost 4 degrees twisted. The Atlas on the right is at just 1.5 degrees.

The atlas on the left is almost 4 degrees twisted. The Atlas on the right is at just 1.5 degrees.

Because if we can play a role in making the brain more resilient, then it has the best chance to make itself resistant the the pain you may experience in your day to day life.

Talk to Dr. Chung

 

FIbromyalgia and the Atlas

Fibromyalgia and the Atlas

FIbromyalgia and the Atlas

 

Read time: [5 minutes]

 

Fibromyalgia Syndrome (FMS) and other conditions involving chronic pain are among the most frustrating conditions that affect a human being. While the condition is not life threatening, it is without a doubt life impairing.

While the pain of a surgical procedure, broken bone, or acute disc injury can be more excruciating, the pain from those tissue injuries will tend to decrease over time. Pain from FMS is unique in the fact that there is frequently no injury to treat and the pain seems to have no expiration date. That patients must learn to live with the expectation that it may never go away.

This can make you feel a sense of helplessness if you have been diagnosed with FMS. If you have fibromyalgia, it’s common for you to just feel run down, tired, and in agony but you don’t know why. This results in friends and family members feeling like you’re a hypochondriac, and often results in ostracizing the afflicted patient.

Fibromyalgia Syndrome and The Need for Integrative Care

Despite what many gurus, vitamin peddlers, and book sellers say, there is no cure for fibromyalgia. There are so many co-morbid illnesses tied with fibromyalgia that it has turned into a syndrome (FMS) as opposed to a single chronic pain entity. These symptoms include pain, brain fog, chronic fatigue, irritable bowel syndrome, and headaches. That is a wide variety of symptoms for one illness, and each have their own physiology behind it.

From that stand point, it wouldn’t make sense to try to have a one treatment fits all strategy to a condition like FMS.

Conventional treatment focuses on medications, progressive exercise, sleep disorder treatment, and psychotherapy to help control the pain of fibromyalgia. Exercise in particular has a strong track record for therapeutic benefit in FMS.

However, one of the things that I’ve seen after spending time hundreds of patients with fibromyalgia is that they find the mere thought of doing exercise to be overwhelming. Patients also find the idea of getting psychological therapy to be condescending to their condition despite the evidence that it is helpful.

fibroinfographic

All of this makes an evidence-based approach to fibromyalgia syndrome to be extremely challenging at this point in time. The end result is that new, experimental, alternative, and potentially pseudoscientific methodologies become entrusted to improve the quality of life in patients with this condition.

For decades, chiropractic and spinal manipulation has generally been lumped into this category. However, the growing amount of research is showing that manual procedures in the spine do have a real impact on the central nervous system. One study released last year tackled the fibromyalgia problem with some promising results.

The Addition of Upper Cervical Manipuluative therapy in the treatment of patients with Fibromyalgia: A Randomized Controlled Trial

Abstract Link

A clinical trial was published in the journal Rheumatology International. The authors looked at the addition of upper cervical spinal manipulation to a comprehensive fibromyalgia treatment regiment to see if it any effect on outcomes.

The standard treatment for fibromyalgia includes cognitive behavioral therapy, light exercise recommendations, and pain education. This study compared standard treatment alone and compared it to when standard treatment included manipulation of the upper neck. The patients were treated for about 12 weeks and had a follow up appointment in a year.

They measured changes in pain, sleep, anxiety, posture, and quality of life.

Results

Interestingly enough, the group that received upper cervical manipulation didn’t have a significantly better outcome than the standard treatment group after 12 weeks. Both groups improved in their symptoms, but there wasn’t much difference between the 2 groups. On a good note, the postural measurements of the upper cervical group did improve quite a bit.

Here’s where the magic is:

At a one year follow up, the upper cervical manipulation group continued to show better control of their pain, sleep, anxiety, and posture even though they stopped getting manipulations. On the other side, the control group actually started to regress towards their original scores.


Whoa

Important Notes

  • The study used a physical therapy technique called the Maitland Concepts. It’s not a chiropractic technique, but has elements of high velocity, low amplitude manipulation commonly found in chiropractic.
  • The patients continued to get better even after they stopped getting manipulation. A common knock against manual techniques is that you need to keep getting adjustments in order to feel better. The multi-modal approach used in this study suggests that patients can continue to get better even after treatment is done.
  • The authors showed that manipulating the neck created widespread changes in the patients’ posture measurements including the low back, shoulders, etc. They attribute this to the fact that the upper neck is a critical element to controlling the posture of the body.

Conclusions

You all know my biases as a chiropractor that uses a niche technique. The truth is, I don’t care about what techniques I end up using, or whether the technique was created by a chiropractor, physical therapist, or a marine biologist. All that matters is that people get great outcomes!

I love this study because it shows that changing the physical structure of the body can happen through the neck, and doing this can get people a great long term outcome from an illness that makes millions of people miserable.

Ask Dr. Chung a question