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Dysautonomia and Fibromyalgia

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By Dr. Samuel K. Yue, M.D. • • June 5, 2001

Dr. Samuel K. Yue, M.D.
Clinical Medical Director, HealthEast Pain Clinic
HealthEast Bethesda Lutheran Hospital & rehabilitation Center, St. Paul, Minnesota

Dysautonomia applies quite often to fibromyalgia patients. The term dysautonomia describes a delayed, inappropriate and exaggerated autonomic nervous system response to an external or internal stimuli that has long passed. The autonomic nervous system (ANS) or the primitive and unconscious part of our mind controls every aspect of our internal organs and their functions.

ANS consists of two major components, namely the sympathetic and the parasympathetic. The sympathetic nervous system of the ANS initiated organ functions such as: increase heart rate, increases smooth muscle tone of the bowel (decreases bowel motility i.e. tight bowel or constipation), decreases blood flow and increases the blood pressure (increases constriction of the smooth muscle of the blood vessels wall), constricts the pupil, etc. The parasympathetic nervous system however does exactly the opposite. The end organs depending on the different stage of its assigned function initiates nervous signal to the ANS which will respond with either sympathetic or parasympathetic nervous signals increasing or decreasing the activities or functions of the end organs.

In harmony and balance, internal organs' nervous signals to the ANS (afferent impulse) are perfectly matched by the outflow of sympathetic or parasympathetic nervous signals (efferent impulse) to the organs. These organs then perform optimally and efficiently which reflect externally as health and wellness of the individual.

Nerve endings and their end organs in fibromyalgia behave as if "denervated". Denervation is a physiological term used to describe when a nerve to the organ is cut and how the organ responds to stimulation. It consists of 4-phased responses that differ from a normal organ: 1. "Super-duration response", 2 "Hyper-excitability", 3. "Increased susceptibility", 4. "Super-reactivity". Initially the organ does not respond to any of the stimulation until a higher than normal threshold is reached. Once the threshold is reached, the organ responds maximally. Any further stimulation will cause significantly more response and the response is exaggerated. The organ behaves with a delayed all or nothing response. This is the basic law of Cannon described in physiology concerning the responses of any denervated organs.

The organs of fibromyalgia patients respond as if they are denervated. The smooth muscles within the organs of fibromyalgia patient do not stretch well and the nerve endings that conduct the signal to the brain or the central nervous system is often delayed. In combination these factors produce a denervation effect on many of the organs. I will use an example, panic attack - what is often considered to be an attack of no known etiology, to illustrate the delayed action of the nerve endings and the secretion of stress hormone from the organs. When a normal person is under stress, the stress responses begin. Both mental and physical stress triggers the production of stress hormones from the adrenal gland and from the central nervous system. These hormones have a tendency to increase the heart rate, cause jitteriness or nervous energy, increase breath rate, and cause a sense of urgency that things need to be accomplished. Hormones are secreted in response to stressful conditions of various types.

The organs of fibromyalgia patients do not secrete the stress hormones appropriately. When they are under stress, the stress hormones are not released during the stressful period. They just keep working, utilizing normal energy and feeling exhausted from the whole ordeal. Eventually the ordeal is over, they get to go home to rest (super-duration). Any additional physical activity or any mental activity causes the threshold level to be reached and the stress hormones begin to be dumped into the body (hyper-excitability). The patient experiences a rapid heart rate, a sense of urgency, and shortness of breath. Adrenaline begins to circulate in the body and the patient feels hot, cold or sweaty.

Because the person is not doing anything stressful at that particular moment and can see no significant precipitating factor to elicit this type of response, the patient may become more fearful. The patient begins to hyperventilate and the heart rate goes up faster, inducing extra adrenaline to be secreted and the other stress hormones to be released rapidly (super-susceptibility). Eventually the patient reaches a point of extreme panic (super-reactivity) and are often brought to the Emergency Room for work up and to be treated with various medications and sent home with usually negative findings.

Within a short time the same process will be repeated. These cycles will continue until all the stress hormones are exhausted from the adrenal glands and from the central nervous system. Then the cycles will stop so that the body can regenerate all of the stress hormones. If these patients will later again experience another stressful condition until the delayed threshold is reached, the panic attach cycle will repeat itself. Therefore dysautonomia of the hormonal stress response elicits what many times people consider to be panic attacks of unknown etiology.

Dysautonomia affects the GI tract of fibromyalgia patients in various ways. The GI tract within our body serves two major functions. The two functions are to digest the food and propel the waste from the body. The urge to eat is influenced by both the external and internal stimuli. In the external environment the sound, the smell, the visual image of food, the time of the day, the occasion, all stimulate the person's urge and appetite and the need to eat. Internally many things happen to cause the appetite to increase, including the time of day, the release of hormones and the glucose level. The hormonal level of insulin also directly affects glucose level. In women hormonal influence is well known to affect the sense of well being and increase the appetite.

The autonomic nervous system controls every aspect of digestion and propulsion of food. When food is put into the mouth, saliva is secreted to begin the very first process of digesting food. After the foods are chewed properly, swallowing is initiated, the autonomic nervous system then takes over and causes the esophagus to dilate and contract and slowly propel the chewed food particles into the stomach. Every aspect of food digestion and propulsion, after the conscious act of swallow, is an unconscious or autonomic nervous function. The stomach begins to move more actively and secretes acid and enzymes, further digesting the food and propels the food down the GI tract. The GI tract also begins to move more actively and secrete all types of digestive juices or enzymes to further break down the food into essential nutrients that can be easily absorbed. As these digested foods are propelled down the GI tract, the nutrients are absorbed through the mucosa into the body.

The autonomic nervous system also controls many GI reflexes. For example, early in the morning, drinking a cup of coffee or eating breakfast will stimulate and initiate the gastroenteric reflex directly down the GI tract so that the urge to defecate is almost immediate. The autonomic nervous system helps the body digest food and excrete waste.

Fibromyalgia patients often have difficulty with digestion. To understand the problem we need to look into the working mechanisms of our GI tract. In addition to propel and digest food the GI track has to protect us from some of the harmful effects of spoiled food or toxins that occasionally may come with the food we ingest to the stomach.

If we eat something that is toxic to our body or "disagrees" with us, the first thing that happens is that the entire GI track shuts down. We do not feel well and experience bloating of the stomach. The stomach lining and the GI tract produce a watery secretion to dilute this toxin. When the threshold is reached, and if the food is in the upper part of the GI tract, reverse peristalsis occurs, and we regurgitate or vomit the food. Quite often we feel better because the toxic material is removed from the stomach.

If the food has passed through the stomach, we experience GI discomfort, bloating, gas, pain, and sense of doom. The bowel becomes irritated from the toxic material and produces secretions to neutralize the toxins. The autonomic nervous system initiates painful movement down the spastic and tight bowel leading to diarrhea, which propels all the toxins out of the body. Almost everybody has experienced this type of GI track reaction to bad or "toxic" food that we occasionally partake.

For fibromyalgia patients, these unpleasant functions are experienced in normal instances. For example when eating food, fibromyalgia patients may not secrete sufficient saliva. The mouth is too dry while they are eating, but may produces saliva after they finished eating. The response of the saliva glands to food stimuli within the mouth is delayed. Once the food is washed down, the stomach responds quickly to the food as if the food is somewhat toxic. The stomach slows down and does not secrete sufficient gastric acid and enzymes to neutralize the "richness" of the food. They then begin to experience a bloated feeling, gurgling sensations within the stomach, and a painful gas and bowel movement as the not well digested food slowly and forcefully moves from the stomach to the GI tract. Rich food with high oil and fat content heighten this type of problem, commonly described as dyspepsia after eating.

There are two main digestive problems, which affect many fibromyalgia patients: irritable bowel/spastic colon, and leaky gut. The irritable bowel or spastic colons are used to describe the propulsion of food through our GI tract, whereas leaky gut is used to describe the malabsorption of the nutrients within the GI track.

The irritable bowel/spastic colon will be described first. Normally the foods are slowly propelled down the GI tract. Within 24 hours the non-absorbed but digested food slowly accumulates in the colon to be later evacuated. Because of the dysautonomia or the all or nothing type of autonomic response in fibromyalgia patients, the bowel behaves strangely and in extreme. The bowel either is too tight or too loose, resulting in constipation alternating with diarrhea.

Initially the bowel may be too tight as in constipation, but the organ signals to the ANS (afferent impulses) is delayed until finally the threshold is reached and the signal is sufficiently strong to be recognized by the ANS. The parasympathetic response from the ANS will be initiated (efferent impulses) which stimulates the bowel to relax maximally resulting in diarrhea.

Once the diarrhea begins the bowel and the ANS will attempt to reverse this condition, which over a few days revert back to constipation. Irritable bowel syndrome describes these yo-yo effects of constipation alternating with diarrhea together with the malabsorption difficulty. Dysautonomia in this instance describes the inability of the ANS to control and balance the bowel's function so that it behaves in both extremes instead of optimal functions. Constipation is related to higher sympathetic flow, which is more typical in fibromyalgia patients, so constipation part of this yo-yo cycle predominates.

Most fibromyalgia patients experience longer period of constipation alternating with a few days of diarrhea. This diarrhea phase is usually more welcomed before the constipation phase begins anew. However, on those fibromyalgia patients where diarrhea predominates, malabsorption is further exaggerated which will be discussed later. Those fibromyalgia patients who constitutionally have a problem with their bowels rarely experience diarrhea. The sympathetic outflow is high congenitally and coupled with the disease which increases this outflow further.

This constant state of constipation alternating with occasionally short brief or no period of looser bowel movement is called spastic colon. The autonomic nervous system lost the ability to regulate the bowel and to revert the excessive sympathetic outflow. Once a day bowel movement is rare in these patients, they may evacuate their bowel on a weekly basis. Stool softeners and other bowel movement aids are often needed just to initiate a bowel movement. Many of them have become dependent on these aids for any bowel movement.

Irritable bowel/spastic colon often aggravates the leaky gut syndrome. The leaky gut syndrome describes how our body absorbs nutrients. The mucosa (lining of the bowel) reacts to the nutrients within the bowel through the autonomic nervous system. It acts as a sieve to filter the necessary nutrients into the blood stream so that the body can utilize them. The closing and opening of the sieve to allow the passage of nutrients is directly related to the autonomic nervous system (sympathetic Vs parasympathetic).

Because of dysautonomia, fibromyalgia patients close or open maximally these sieves on the mucosa at the inappropriate time. Poorly digested foods and the breakdown nutrients are either completely passed over or not absorbed by the closed mucosa or maximally absorbed by the opened mucosa. When undigested small foreign proteins are passed from the maximally opened mucosa into the blood stream, allergic reaction begins. The degree of reaction depends on the amount of foreign proteins absorbed. Severe anaphylactic reactions may occur which at times may lead to death of the individual.

It is interesting to note that many fibromyalgia patients related to the fact that they have been eating the same "allergic" food their entire life only to discovery that the allergy develops when fibromyalgia condition progresses. The allergy results from the bowel's inability to digest food properly and the absorption of foreign undigested protein into the body secondary to dysautonomia. When protein is partially digested in the gut, accumulation of certain amount of digested nutrient will cross the threshold, initiates the opening of the sieve within the mucosa to facilitate absorption. Because of dysautonomia and the maximally opened sieve, the undigested or partially digested small foreign proteins that are usually not absorbed is now filtered into the blood stream. When that happens, the body perceives these proteins as foreign substances and mounts an allergic reaction to these proteins. Suddenly the person develops a rash, hives, swelling, high fever and palpitation.

It is interesting to note that some patients will remark that, " I can eat one egg, but if I eat two eggs I will be in trouble." It takes a certain amount of digested and undigested protein within the GI tract of high enough concentration to stimulate and initiate the threshold in the mucosa before dysautonomia sets in and the sieve within the mucosa opens maximally. The severity of the leaky gut syndrome is related to the blood supply at that time when the protein leaks into the body (dysautonomia of the blood vessels). If the blood supply is minimal secondary to tightness of the smooth muscle to the blood vessel wall, a relatively small amount of the protein will leak into the blood stream. Allergic reaction is minimal. When the blood vessels open maximally various types of small and medium size foreign proteins that are not supposed to be absorbed are absorbed into the blood stream, moving very quickly to the rest of the body, a severe allergic reaction results.

Fibromyalgia patients also develop multiple "allergies" to many medications. Initially the medications do not seem to work on these patients because they are not absorbed into the body. They are usually instructed to increase their dosage. Unfortunately when the threshold is reached the sieve opens up completely and the medications will be dumped maximally into the blood stream. At this point every single side effect will begin to manifest on this poor patient. These heightened reactions to many medications lead the patients and their physicians to labeled themselves as sensitive or allergic to multiple medicines. So allergy, chemical sensitivity, food intolerance, malabsoprtion and irritable bowel/spastic colon are the result of dysautonomia of the mucosa, motility and blood supply of the GI track.

The whole digestive system is controlled by the autonomic nervous system. When the autonomic nervous system is delayed or has denervation type of effect, the body will exhibit "unusual symptoms" that puzzle many physicians. Western physicians do not seem to pay much attention to this autonomic nervous system whereas classic Chinese medicine places an extremely important role of the autonomic system since it controls the inside of the body and the inside is reflected on the outside of the body. Fibromyalgia patient may have rough or dry skin at all times, rough or brittle nails, and brittle hair. These signs reflect internal problems as in the mucosa dysfunction of the GI track. They may be susceptible to infections. Even the immune system is directly and indirectly affected by the autonomic nervous system.

Many of the nonspecific complaints of fibromyalgia patients can be attributed to dysautonomia. Dysautonomia can be used to explain why the person has a regulatory temperature difficulty resulting in cold feet and hands. It can also be used to explain why people have Raynaud's Phenomenon on the fingers. Dysautonomia can also be used to explain why patients get dryness of the mouth and dryness of the tear ducts. Glucose intolerance is also a result of autonomic dysfunction. With hyper or hypoglycemia, glucose stimulates the secretion of insulin which is delayed in fibromyalgia. When the sugar reaches a certain threshold, the insulin rushes out to immediately drop the level of glucose. The secretion of insulin, however, overcompensates leading to a low serum glucose, resulting in hypoglycemia. These patients fell hungry and wish to eat and repeat the cycle. Many normal but prediabetic patients also experience this hyper/hypoglycemic cycle. In addition, many other hormonal responses to internal and external stress and menstruation cycle also aggravate the hyper/hypoglycemic state of these patients.

In summary, I believe that many usual and unusual complaints of fibromyalgia patients related to the digestive system can be explained as dysautonomia or "denervation effect" of the nerve endings and its effects on the end organs. These usual and unusual signs/symptoms that are seemingly unrelated, prompt many fibromyalgia patients to seek medical help in various specialties. Since both the patients and the physicians are unaware that the same set of S/Ss are related to fibromyalgia, extensive work up are usually ordered on these patients with mostly negative results. When all results are negative, physicians are at a loss to explain these S/Ss and the patients return home with the most unsettling feeling of their body since these S/Ss are so "real" to them. Addressing the issue of dysautonomia and its effect on these patients will assure these patients that their S/Ss are real and that the S/Ss may be controlled by many therapies: including relaxin replacement, enzymes replacement, food avoidance and good colon hygiene.

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