Dr. Sarah Myhill is a UK-based physician and clinical nutritionist with a special interest in the treatment of fatigue, chronic fatigue syndrome (ME/CFS), and fibromyalgia (DrMyhill.co.uk).
Normally, pain is accompanied by healing and repair, and this involves inflammation. But when things get complicated, as with autoimmune activity, fibromyalgia and ME/CFS, it is almost impossible to tease apart the threads of chronic pain, chronic fatigue and inflammation. And it is a combined approach that gets results.
Pain… and Pain that Doesn’t Go Away
Although pain seems like ‘a pain’, actually it is essential for our survival. Pain protects us from ourselves. It prevents us from damaging our bodies. Indeed people who are born with no pain perception look as if they have been traumatized! They are covered in cuts, bruises, sores, because they do not realize that they are damaging themselves.
Pain is the local method of avoiding damage – it makes us protect the affected part of the body and makes us keep it still so that healing and repair can take place.
If pain becomes more generalized, then it is accompanied by fatigue. What this means is that chronic pain and chronic fatigue go hand in hand and therefore so does the treatment.
We learn through experience what is painful; this makes us avoid those painful experiences and therefore protects our bodies. Although it is desirable to learn about pain this can also cause problems, because if the underlying causes of the pain are not identified the body will ‘learn’ more pain (as discussed below).
In the ideal situation we damage our bodies with, say, a cut or bruise, the local pain makes us care for that damaged area by protecting it and keeping it still so that healing and repair can take place. With healing the pain goes.
What Happens If the Pain Does Not Go?
If the root source of the pain is not identified it creates a problem because then the pain increases. The body naturally thinks that increasing pain means we will take more care, identify the source of the pain, keep the limb more still, and therefore the body winds up the pain signal to try to elicit the appropriate response.
Effectively we learn to feel more pain because there is an upgrading of this pain response. This is not a psychological effect – it actually occurs within the cells themselves. This makes it very important to identify causes of pain and allow time for healing and repair, otherwise the pain will get worse.
Sleep, Pain and Pleasure
The best time for healing and repair occurs during sleep. If we lose sleep we are slow to repair. Furthermore we cannot make many of the hormones and neurotransmitters which down-regulate pain. These include dopamine and opiates.
Dopamine and opiates are a central part of the pain and pleasure reward system. The two things go together, creating evolutionary drives which direct us to act in the right direction. So for example when we need food we get a hunger pain and that hunger pain is satisfied by eating, which gives us pleasure. If we lost these associations we would quickly die from anorexia! Indeed all the actions that we take to ensure our survival are driven by this pain-pleasure axis.
Pain is driven by dopamine – dopamine drives us to initiate things and make things happen and the reward is a release of our endogenous opiates or endorphins. So, for example, a young man who wishes to procreate his genes will suffer all the pains of courtship, but will be rewarded by endorphins when he finally jumps into bed with his beloved!
The problem for many physicians is that most people with chronic pain present some way down the line with ‘learned’ responses well established.
Often by the time they get to see doctors they have a learned pain response, their pain threshold is low, chronic pain is associated with chronic fatigue, sleep is disturbed and this compounds all the above problems.
Treatment of Chronic Pain
Try to Identify the Causes of the Pain
This is where investigations such as MRI scans can be very useful. A major cause of many pains comes from the diet – either through allergies, pro-inflammatory effects of sugar and refined carbohydrates, toxic load from too much food, toxic load from social drugs (caffeine, alcohol), or prescription medication.
Finding the cause is important for very obvious reasons. Many people are tempted to use painkillers, but the problem here is that although these work fine in the short term, in the long term the body adapts to these painkillers and they become ineffective.
Always think total load – local triggers plus dietary triggers can amount to an intolerable situation!
Identify Useless Inflammations and Remedy Them
Pain almost invariably is accompanied by healing and repair and this involves inflammation. A certain amount of inflammation of course is essential, but too much becomes destructive. Inflammations from allergy or auto-immunity are useless inflammations.
Inflammation, like pain, can also become a learned effect and become self-perpetuating. Central to this is the NO/ONOO- cycle (well described by Professor Martin Pall) in which there is a vicious feedback mechanism initiated by certain short-term stressors like viral infection, toxin exposures or physical injury that winds up inflammation. See “Inflammation.”
Essential fatty acids (EFAs). Having good levels of omega-3 (e.g., fish oil) and omega-6 (e.g., flax seed oil) essential fatty acids feeds into prostaglandins and prostacyclins and leukotrienes – which are essential messengers within the immune system. A low fat diet so beloved of the “cholesterol can be reduced by diet” school of thought will result in a pro-inflammatory tendency. High dose essential fatty acids can be most helpful.
Vitamin D. Vitamin D is the sunshine vitamin and made as a result of the action of ultraviolet light on skin. Sunshine is pro-inflammatory, and to mitigate this the body has evolved a system of making vitamin D, which is anti-inflammatory. Humans evolved running naked under the African sunshine getting lots of vitamin D – it diffuses from the skin to the rest of the body where it has a generalized anti-inflammatory effect. (See Vitamin D – Most of Us Don’t Get Enough.)
The further away from the Equator one lives, the more diseases one sees associated with inflammation such as autoimmunity, allergies, multiple sclerosis, heart disease, cancer and so on. I like everybody to have at least 2,000 iu of vitamin D daily and where there is a clear pro-inflammatory tendency I use 50,000 iu weekly.
Vitamin B-12. This has a marked down regulating effect on the NO/ONOO- cycle because it mops up peroxynitrite, a free radical resulting from superoxide dismutase and nitric oxide combining. The central player in Prof. Pall’s vicious NO/ONOO- cycle is NMDA – a receptor which stimulates inflammation.
Antioxidants. Much inflammation is caused by free radicals, and having good antioxidant status will help protect against this. See Antioxidants.
Foods and diet. Western diets are pro-inflammatory. Humans can eat a wider variety of food than any other animal and this is because they have amazing ability to detoxify foods via the P450 enzyme detox system. If this system does not work efficiently then foods and other chemicals, instead of being detoxified generate free radicals, and this can be highly damaging and pro-inflammatory.
Tweak Neurotransmitter and Hormone Levels in Order to Increase Pain Thresholds
As we age, our ability to produce neurotransmitters which guide and shape our behavior declines. There are many things we can do to boost endogenous production of neurotransmitters and therefore increase pain threshold. This is covered at length in Eric Braverman’s book The Edge Effect, which describes the brain in terms of the actions of the four neurotransmitters and the symptoms of imbalance associated with each [see Dr. Myhill’s summary of Braverman’s four neurotransmitter-influenced personality types]. But a few examples of helpful things are given below.
Acetylcholine. Increasing levels of acetylcholine is probably the mechanism by which anticholinergic antidepressants help pain. A small dose of amitriptyline at night for example can be a useful pain killer.
GABA. This is the main neurotransmitter which tells us to chill out – the main drugs which work on this are benzodiazepines and gabapentin. However, we can increase our own production: Green tea contains threonine, an amino acid and so-called “adaptogen” which stimulates GABA production. Meditation is also known to increase GABA levels.
Dopamine. Again, dopamine is the neurotransmitter which allows us to anticipate a reward. The sensation of reward comes from endogenous opiates (produced by the body). So exercise and sexual activity are obvious examples. With exercise there is obviously a pain to be experienced in running, but once one has got over a certain threshold we then get the opiate buzz.
Caffeine stimulates dopamine release and is often helpful in pain relief. Adrenalin (and noradrenalin) form downstream from dopamine – they accumulate in the adrenal gland during sleep and are released in pulses to help us cope with stress during the day. No sleep and no adrenalin, so poor stress tolerance!
Serotonin. Levels are increased by full spectrum light and sunshine, together with aerobic exercise and increasing muscle strength. Keeping fit is good for our neurotransmitters and our pain thresholds. Chocolate (not with the milk and sugar bits!) raises serotonin levels.
Low dose naltrexone. Is a technique of proven value to increase brain production of our own opiates endorphins. See Low dose naltrexone website.
Minerals. Broadly speaking sodium and calcium excites nerves and muscles, whereas magnesium and potassium relaxes them and switches them off. So one would expect the latter two to reduce pain thresholds. This is certainly my clinical experience. Magnesium has been dubbed “Nature’s tranquilizer.” (See Magnesium – treating a deficiency.) Potassium is abundant in vegetables, nuts and seeds and there is good reason to eat these foods daily.
Electrical techniques. These undoubtedly have an effect on neurotransmitter levels. There are many available – acupuncture is an obvious example, as indeed are TENS machines (Transcutaneous Electrical Nerve Stimulation). I am currently trying a gadget called an Alpha-Stim to see if this will be useful…
Interestingly an alkali environment in the blood switches nerves off, whilst an acid environment switches them on. Indeed, it is possibly this that drives hyperventilation – when we hyperventilate there is a temporary alkalinization of the blood. However, this is not sustained because the kidney quickly compensates by excreting bicarbonate. (See “Acid-Alkali Imbalance – Can Be a Factor in Fatigue, Muscle Pain and More.”
Without good quality sleep and enough of it, all the above interventions will not work well. (See Sleep is vital for good health – especially in CFS.) Sleep is disturbed by pain and if this is the case then some sort of pain killing drug may be necessary to allow sleep. If the pain killers alone are insufficient then sleep tablets such as benzodiazepines should be used.
Improve energy supply
Many people can distract themselves from their pain but only if they have the energy to do so. Chronic pain and chronic fatigue go together – help one and you will help the other.
Many of the treatments for both are the same! See <a href="http://www.drmyhill.co.uk/wiki/CFS_-_The_Central_Cause:_Mitochondrial_Failure
” target=”_blank”>CFS – the central cause: mitochondrial failure.
When things get complicated, it is often almost impossible to tease apart the threads of chronic pain, chronic fatigue and inflammation and it is the combined approach that gets the results.
This article is reproduced with kind permission from Dr. Sarah Myhill’s educational website (DrMyhill.co.uk)® Sarah Myhill Limited, Registered in England and Wales: Reg. No. 4545198.
Note: This information has not been reviewed by the FDA. It is for general information purposes only; it represents the research and opinions of Dr. Myhill unless otherwise indicated; is not meant to replace the personal attention of a medical doctor; and is not intended to prevent, diagnose, treat or cure any condition, illness or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.