Category Archives: Fibromyalgia



VulvodyniaVulvodynia is a painful condition, often exquisitely so, located in the vulva, which is the skin surrounding the vagina. Usually unexplained, this troubling condition can arise seemingly from nowhere, interfere with intimate relations and hence attempts to conceive. Vulvodynia is also known as a functional pain syndrome–these are painful problems that lack a pathology of note that explains the extent of the pain and include irritable bowel syndrome, fibromyalgia, TMJ dysfunction, migraine and pelvic pain. Functional pain syndromes are often concurrent with hypermobility, anxiety and depression, a further common character trait being perfectionism and a tendency for the person to be hard on themselves thereby creating a cycle of chronic stress.

The pain of vulvodynia is often very localised and triggered by direct contact. Naturally this occurs during sex and touch, but sometimes sitting position can bring on the pain. As with any sensitisation, there is a primary location of pain but there can also be a secondary area surrounding that is due to central nervous system (and other systems) involvement. Suspected vulvodynia or other pains in the pelvis should be assessed and examined by a gynaecologist as a first step before beginning treatment, and by a consultant who knows and understands both the condition and the impact — Miss Deborah Boyle at 132 Harley Street.

With vulvodynia often being part of an overall picture of sensitivity, it means that there is a common biological adaptation that is upstream of the range of seemingly different conditions (the functional pain syndromes). As soon as the individual understands that pain is not an accurate indicator if tissue damage, but rather a reflection of the perceived threat and prioritisation by the body-person, there is a realisation that the pain can change. Pain can change because perceptions can change as we take on board new information and consequently think and act differently, creating new habits. The new habits set the conditions for on-going and sustained change that includes overcoming pain.

We have limited attention and hence can only be aware of certain amount of stimuli in any given moment. If pain is consuming much or all of your attention and consciousness, then this is all that is happening in that moment, with all other possible experiences being disregarded–it is a matter of prioritisation. When the perception of threat is reduced by a constructive thought or action, the pain moves out of our attention span and we become aware of other thoughts, feelings and experiences. How we respond to pain is unique and learned through our lifetime right up until that point; all those bumps and bruises as a child, how our parents reacted, more serious injuries or illnesses and the messages we received from doctors, teachers and other ‘big people’, then through adult life, moulding our beliefs about ourselves, the world, health and pain each time we feel it. The sum of all this activity, most of which we are unaware of, sets up how you respond to the next ache, pain or injury, blended of course with genetics. It seems that some people are genetically set up to be more inflammatory, meaning that responses to injury are potentially more vigorous and go on for longer. Understanding this means that the right messages and treatment can be given, thereby appropriately addressing the injury or pain. One of the big problems is that this does not happen, and the explanations are structural and based upon the body tissues. This ignores the fact that we have body systems that protect and these systems have sampling mechanisms in the tissues and organs but largely exist elsewhere–e.g./ nervous system, autonomic nervous system, endocrine system, sensorimotor system, immune system. We have to go upstream as well as improve the health and mobility of the local tissues.

Going upstream is vital in overcoming vulvodynia, and this is where the Pain Coach Programme works–this is my part of the treatment programme. You may also choose to work with a women’s health physiotherapist who will work more locally. So what is the Pain Coach Programme?

The Pain Coach Programme is a a blend of the latest neuroscience of pain with a strengths based coaching approach to success. Understanding your pain and that you have the biology and strengths to overcome your pain is a vital start point. You have been successful in the past using these strengths, and you can do so again by drawing on these characteristics and using them to develop your health in terms of how you think and act. Overcoming pain is all about resuming a meaningful life, engaging with activities and people as you want to, in a way that allows you to flourish. The Pain Coach Programme provides you with the knowledge and skills that you need to in effect become your own coach, moment to moment making clear decisions that take you towards your vision of how you want to live. This alongside treatment and specific training to develop normal movement and a healthy body-mind. The skills you learn also help you to fully engage in life, whether this be at home, at work or at play.

If you suffer vulvodynia or other painful problems, call us now to start your programme: 07518 445493


The problem of migraine

migraine by r. nial bradshaw (2012)

migraine by r. nial bradshaw (2012)

The problem of migraine is bigger than most people realise. In fact, the problem of chronic pain is bigger than most people realise, this being apparent as I purposely ask people I know and meet if they know what is the number one global health burden. It is chronic pain by the way, and migraine and headache sit in the top 10 along with back pain, neck pain and osteoarthritis. Depression is at number 2.

Migraine is sometimes referred to as a functional pain syndrome. Not everyone likes this term, myself included, yet it’s use does mean that we can consider migraine as one of a number of conditions that hurt and cause great suffering. These conditions have a common biology known as central sensitisation, meaning that the individual’s systems that protect are more likely to do so, resulting in persisting pain in many cases.

The other well known functional pain syndromes include irritable bowel syndrome (IBS), temporomandibular disorder (or jaw pain, clicky jaw etc), pelvic pain, dysmennorhoea, vulvodynia, interstitial cystitis, chronic back pain and fibromyalgia. These are often co-morbid with anxiety, depression and hypermobility. As individuals, it is common to find perfectionist or obsessive traits that may be useful in certain arenas such as work, helping to achieve great success, yet in other areas of life cause problems. More women than men report these problems, although I am seeing increasing numbers of men who often describe groin pain as a starter but then we explore the history and discover one or more of the aforementioned list. A further frequent finding is difficulty conceiving, this primarily due to the body systems that protect being persistently fired up (by normal living and exposures as well as stressors), and whilst that person is in such a mode, having children is not on the body’s agenda whereas survival is.

As with most of the functional pains, the story highlights certain vulnerabilities that can increase the likelihood of persisting pain including genetics, epigenetics, early life stressors and prior infections/injuries. These factors sculpt the systems that protect as they learn how to respond as well as becoming increasingly vigilant. The combination therewith creates an individual who is more likely to respond to actual or potential threat with vigorous and prolonged action and behaviours. With anxiety in the mix, this person is then likely to over-worry, which in effect further raises the threat value and heighten the responses even more. And so it goes on.

Rarely are the conditions explained adequately to patients, and certainly knowledge of the link between the seemingly different problems has never been volunteered to me by a patient. Therein lies a problem that the individual is suffering one or more pains and other symptoms (e.g./ tiredness, poor concentration, disrupted sleep, lethargy, flu-like symptoms, brain fog), yet they have no understanding as to why, or how it comes on, or what they can and must do to change the situation and move forward. Explaining the condition(s), the links, what the patient needs to do and what we can do to help and support them over a period of time that we can estimate is a key start point.

Further to the common biology, we can observe in the clinic the posturing, movements, guarding, poor body sense, altered sensorimotor function and the overall manifestation of how that person is feeling through body language and the words they use. We can gather far more information about the person, the whole person, by talking to them, listening to them and their concerns. What is their lived experience? The structured interview does not allow for this conversation. Yes we need some specific questions, but creating an open environment gives the person a chance to talk, feel heard and validated. This sets the scene for specific training, techniques and strategies that need to be used throughout the day and the development of understanding, all of which are the knowledge and skill base that the patient needs to overcome their pain.

No matter how long you have had pain, it can and does change. We are designed to change, and this is happening all the time. We are on a continuum, and we can have a say in where we go. It is a challenge and requires dedication, motivation, resilience and practice, but with the right thinking, action and support, great things can be achieved. I am honoured to see this happen in the clinic every week as people overcome their pain and resume being who they think they should be.

If you are suffering or think that you could be suffering with functional pain syndromes, call me for a chat and we can decide what you need to do to start overcoming your pain: 07518 445493

Clinics in Harley Street, Chelsea and New Malden Diagnostic Centre


Fibromyalgia in women | #fibromyalgia

I see many women suffering with fibromyalgia. I also see many women who have widespread aches and pains, frequently without an injury, but rather a gradual increase in pain across the body. This maybe fibromyalgia, but in essence we are talking about sensitisation that evolves if no action is taken.

The commonest profile is this: a woman with young children (may have had some problems conceiving), aches and pains across the body, disturbed sleep or too little sleep, always tired, emotions and mood vary, concentration and focus can wax and wane, irritable bowel syndrome (IBS — bloating, pain), migraines, headaches, jaw pain (perhaps grinding in her sleep), anxious, ‘stressy’, very little time to rest and recuperate, repeated bladder infections (often there is no actual infection, but the symptoms are the same) and poor recovery from illnesses. 

There is a common biological thread with these problems. On appearance it would be logical to assume that they are unrelated — many healthcare professionals also take this view. BUT, this is not the case. These functional pain syndromes are all manifest of adaptations in the nervous system, immune system, autonomic nervous system and endocrine system. The good news is that the changes are not set in stone because we are mouldable, or plastic. We learn and adapt according to our thinking, beliefs and actions.

Understanding your pain changes your thinking so this is the initial step. Thoughts are based on beliefs and evolve to ‘I can change my pain’ when you know the facts. First setting up your thinking, then creating a vision to aim for and finally making a definite plan to follow allows you to head towards sustainable change with healthy habits. It is a challenge, but one that is wholly worthwhile.

Women in Pain Clinic is based at 132 Harley Street in London — call now to start your programme and move forward 07932 689081




Where have ‘I’ gone?

Neuroscience focuses upon the brain. Neuroscience has shown us that the brain is involved with pain. Consequently the brain has been blamed for pain, the unpleasant motivator that is designed to grab our attention and enforce action that protects us from a threat, actual or potential.

Recent thinking that sensibly gathers paradigms from both neuroscience and philosophy challenges us to re-consider the brain-based explanation for pain, even if we are bringing other body systems into the frame. Mick Thacker argues that pain must come from the whole person, not a part of that person. Whilst I have always subscribed to a holistic view, considering all the dimensions of a pain experience (physical, cognitive, emotional), I have been guilty of the journeying on the brain train. As ever though, our knowledge and ways of thinking and using the knowledge evolve and now pain must be thought of as a holistic expression of the whole person.

My left buttock has been hurting for the last three days, so this has provided me with an opportunity to explore this pain and what it means for my ‘self’. It is of course me that is in pain, a localised feeling in the buttock, but nonetheless it is me, myself and I. The pain invades my attention, thoughts, decisions and plans that all involve me and my interaction with the immediate environment in this particular context. Yes this involves my brain, but my brain is me. One organ or one thought does not define me, yet I need both to sense myself.

Listening to a patient describe their pain is to listen to them describing themselves. What I hear and observe in people with persisting pain such as fibromyalgia, is a story of suffering. Suffering is a loss of the sense of self, and that is a whole, not a part. Pain is a feature but so is loneliness, avoidance, fear, anxiety and isolation. So are we just trying to change pain as this is the most frequent request made by patients? In my view, we are seeking to create the conditions for change in a direction that reduces suffering, this of course including the easing of symptoms. We can only achieve this by working with the whole person and not a part.

Although there is much talk about the pain during a session, what is often verbalised and demonstrated is a change in sense of self. We do not feel the same as before, and certainly as pain persists, this sense alters further. Yes we can identify mechanisms that underpin such change such as adaptations in the brain maps, however it is still the entire person who has the experience. Only by keeping this in mind will we be in the right track with treatment, training and mentoring patients to guide them forward. It must be their whole person that is proactively involved in this journey, cultivating a sense of self that fits with expectation and the vision of how things should be.

Specialist Pain Physio Clinics, London — empathetic treatment, training & mentoring for chronic pain


Fibromyalgia — creating conditions for change

Pain and symptoms can and do change. They can change moment to moment and day to day, but if you suffer persisting symptoms, all of the variations can blend into a long physical and mental struggle. Striving for change needs understanding, motivation, resilience and a plan of how to reach your goals.

Fibromyalgia is biology in action. An integrated response of the nervous system, immune system, autonomic system and endocrine system, all of the manifestations of fibromyalgia are the outputs, the end result of how those systems operate together. Unpleasant and troubling as the pain and symptoms are, this is the body trying to recover and making the individual aware. Most of the processes happen beneath our conscious level, but those that don’t cause suffering, whereby suffering is a loss of a sense of self.

Together the sensations that we feel, the thoughts that we have and the environment around us are the experience. Edelman calls this the econiche, the interaction and end result of this interaction being the individual’s reality. The reality has to be unique: what I see and what you see in the same scene can be different based upon what we know, what we expect, current mood and attention to name a few variables. The same could be said for pain that will be influenced by similar variables. There is a biology of pain and the biology of the influences upon the pain.

My farming analogy that is based upon my belief that pain can change (neuroplasticity — the ability of the nervous system to adapt and learn; it is always changing….there it goes again, it’s just changed. And again), is a useful way of explaining to patients how we think about these systems and interactions, how we have to create the right conditions for change. Much as a farmer will prepare his field and cultivate the best soil for his crops to grow, the individual must take conscious action for the body systems to work towards wellbeing. This is the ‘why?’, with the ‘how?’ being a comprehensive approach that targets the physical, cognitive and emotional dimensions of pain.

Come and see us to find out how you can create the right conditions for changing your pain and symptoms: call 07932 689081


London Fibromyalgia Clinics | London FMS Clinics

London Fibromyalgia Clinics — I think differently about fibromyalgia, functional pain syndromes and chronic pain. Believing that there is a need to challenge the way these problems are addressed, I created a specialist clinic that draws upon neuroscience, philosophy and other disciplines to create innovative and effective ways for individuals to move forward in their lives.

Fibromyalgia is known as a functional pain syndrome, sharing a common biology with other problems such as migraine, irritable bowel syndrome (IBS), pelvic pain, musculoskeletal pain and painful bladder syndrome. This common biology is an adaptation in the central nervous system called central sensitisation with changes in the excitability of the nervous system alongside on-going responses of the immune system. The way that the body systems and the brain adapt and learn means that it has become persistently protective, igniting painful and other responses to a range of normal cues and situations. The sensitivity results in on-going pain and general sickness responses (e.g./ aches and pains, tiredness, fatigue, appetite changes, mood changes, anxiety, loss of concentration, brain fog, altered body sense); the latter just like a feeling of the flu.

Stress often plays a role. Stress is a response to a perceived threat, the meaning of which we give to the situation as an individual. The physiology that follows is designed to protect us from wild animals — either to run away or fight. Whilst this is useful when danger presents itself and in the short-term, if these responses continue, they impact upon the immune system, switch off the digestive system and reproductive system (neither eating or digesting a meal are useful in the face of danger; reproduction is not useful in the face of danger — resulting in a sensitive and/or sluggish gut, and fertility problems), prepare the motor system and mobilise energy in preparation for flight or fight.

It is a combination of genetics and experience that results in the condition. Our genes are moulded by these experiences and to what we are exposed: stress, injury, pathology. Protection is triggered but not turned off, the responses continuing as if there is a problem, even when it is resolved. These on-going responses then create further changes, for example chronic inflammation, and a continued loop that maintains the condition. That is until the circumstances are changed and the conditions created to move out of the loop and onto a route of wellbeing.

Believing that pain can and does change via neuroplasticity, I create bespoke treatment and training programmes for individuals who visit the clinic from all over the UK. The programmes ensure that you fully understand the problems and comprehensively target the biological mechanisms addressing the physical, cognitive and emotional dimensions. I help you to develop the knowledge and skills that you need to move forward in your life with a range of proactive strategies, techniques and treatments grounded in neuroscience.

Call now for more information or to book an appointment: 07518 445493


Persisting pain and chronic stress — how much do they cost your business?

Persisting pain and chronic stress –> 20% of people suffer chronic pain according to recent figures. The number who describe feeling stressed is also high. In many cases, those who are in persisting pain will also feel stress, and those who are chronically stressed will describe on-going aches and pains. Biologically there are links between pain and stress explaining the ‘bed-fellow’ relationship, often involving inflammation.

From a business perspective, if you have a workforce it is likely that there will be a number of people suffering pain and stress. This undoubtedly will affect performance with financial consequences for the business. One of the biggest influences upon performance is the level of happiness that an individual experiences at work.

Stress and thinking

Feelings of stress result from our perception of threat. This is individual and depends upon the meaning that we ascribe to the situation that can be real and in front of us, or to a thought. The bodily sensations associated with stress are well known: tension, increased heart rate, sweatiness, ‘butterflies in the tummy’ (this is actually changing blood flow through the gut) — all are preparation for a fight or to escape from a physical threat; a wild animal.

See Robert Sapolsky talking about stress here

Most of the time we feel stress because of what we are thinking about; the brain not differentiating between a thought and actually being in the situation in terms of the reactions and responses that it initiates. These are of course natural and normal responses if there is a genuine threat. However, if we are consistently kick-starting protective measures when there is no actual threat present, the system becomes increasingly efficient and vigilant, firing off even in innocuous situations. In other words, the body protects itself when it does not need to.


Similar to all experiences there is a chemical basis to stress that manifests as our ‘reality’. In the short-term, the feelings of stress motivate action to deal with the stressor and thereby restore balance, or homeostasis. If the system continues to be provoked, in essence a chronic stress, these chemicals will persist in preparing the body for action, shutting down the gut (or clearing it out), similarly the bladder and reproduction (because there is not much point thinking about sex when you are being chased by a tiger) — and now consider the seeming rise in issues around fertility. The continued release of these chemicals in response to thinking and perceiving threat drives increased muscular activity that begins to hurt (chronic back pain, neck pain, pelvic pain etc), uses much energy that becomes depleted (chronic fatigue), suppresses the immune system (regular infections, poor healing, on-going pain and sensitivity — especially females) and impacts the endocrine system (dysmenorrhoea, anxiety).

Functional pain syndromes & Women in Pain

Many of the common yet significantly troubling conditions are underpinned and heavily influenced by the chemical balance. Chronic stress cultivates inflammation that is normally in delicate balance. Inflammation affects all body systems, sensitising the controlling nervous system that manifests as a painful syndrome: irritable bowel syndrome, pelvic pain, migraine, headache, chronic back pain, TMJ dysfunction, fibromyalgia and bladder dysfunction (recurring infections — or are they? — interstitial cystitis); often accompanied by anxiety and depression. Interestingly there is good evidence that depression has an inflammatory basis.

At work

We can only attend to one activity well at any given moment. Multi-tasking is an illusion — this is just doing many things badly. To maintain our focus and attention requires discipline. When the mind wanders, which it does, we lose focus and attention. If we do not have the ability to control the meanderings and we are taken to places that are troubling through rumination, the body always responds as if we are actually in that place. To become skilled at recognising this as a process and to be able to maintain awareness of the present moment is potent for both health and productivity.

Focused attention training or mindfulness training allows us to become aware of the wandering mind and recognise that the body is responding to thoughts of the past or the creation of a future. Of course neither of these actually exist, they are tapes being played by the brain. They do feel real.

Simple techniques that can be learned and practiced, anchor us to the present moment, disarming the thought. It is just a thought. This does not mean that we stop thinking, and this is impossible as thousands pass through the mind each day. Rather, we can decide which thoughts need attention and those that can be let go as they offer nothing but discomfort. On living out a thought, there is always a physical and emotional response. We become very good at letting this happen automatically, habitually, the so-called autopilot. Creating awareness around this delivers control and clarity that leads to clarity.

And pain

Pain is meant to grab our attention so that we take action. It is a great motivator and this is a vital device for survival. When pain persists beyond a useful time, the adaptations within the body systems and the behaviours we adopt become part of a cycle that becomes increasingly difficult to break. Yet change is always possible with the right understanding of pain and strategies to target the biological mechanisms of pain and those of the influences upon the sensation of pain: stress, fatigue, emotional state, physical activity.

Here’s a great video about pain

Certainly, when pain is the running mode, it directs attention to the body area deemed to require protection. In brief, pain is part of a protective response to a perceived threat, similar to a stress response that equally directs our attention towards something assessed to be dangerous — but it does not have to be actually dangerous for the same set of responses. The body (tissues) is where the pain emerges, yet we require a brain and the densely interconnected highways of communication  between neurones, the brain cells, for the creation of the sensation.

Whilst working the focus needs to be on the task in hand. Pain certainly interrupts this focus, taking up mental resources as the attention both drifts and dwells upon the body part being protected.

Stress and pain

The two are inextricably linked in many ways. To tackle one needs consideration of the other in both mechanism and the drivers that maintain the responses to the perceived threat — recalling that pain and stress are both reactions to the perception that danger exists.

When an individual experiences stress at work it can be due to a feeling of being undervalued or insufficiently challenged. There are many other reasons.

Approaching the problem at work — a brief overview

Much has been written about strategies that the workplace can use to cultivate a positive environment at work. If the employees are valued, have a sense of purpose and support, clearly this will feed into the business. On the other hand, a disconnected and stressed workforce will under-perform within a climate of resentment.

On an individual basis, learning strategies that deal with stress can make an enormous difference. Building resilience and developing positive psychology skills certainly enhances performance at work, cultivating satisfaction and self-esteem.

A practice that has a profound and potent effect upon stress is mindfulness. Becoming skilled at being present by focusing upon breathing disarms the thinking that pulls us into the past or creates a future. The benefits of mindful practice include improved physical health, clarity of thought and enhanced performance. Neuroscientists are now looking at the mechanisms that underpin mindfulness so that we can optimise the effects.

Movement is vital for our health. A work environment should encourage regular movement and permit exercise at lunchtime. Eating at the desk is simply unhealthy, especially when you are concentrating on something other that the food. Recall that the digestive system turns off in stressful situations, hence why so many people describe varying degrees of irritability in their gut.


Individuals suffering stress and chronic pain will be unable to fully focus upon their work. Biologically, attention will not be upon the work for sufficient periods to perform.

A supportive workplace using a range of simple strategies that include supporting those in need, allowing gradual return to work when employees have been off and looking at ways of enhancing performance by cultivating a positive environment with the basics — for example, allowing movement opportunities, healthy snacks and water.

On an individual basis we can tackle pain and stress in a number of ways that should include exercise, movement at work and mindful strategies.

With both the individual and the workplace communicating well and taking responsibility, we can cultivate positive environments for working and performance.


Women and Pain Clinic @ 132 Harley Street

The Women and Pain clinic is dedicated to providing contemporary treatment, training and coaching for females who suffer persisting pain.

Common examples of on-going painful problems include:

  • pelvic pain: including pain from endometriosis, bladder problems, muscular spasm & guarding of the pelvis and abdominal area
  • back pain
  • joint pain (often multiple)
  • abdominal pain (irritable bowel syndrome or similar sensitivities)
  • migraine & headache
  • jaw pain & dysfunction
  • fibromyalgia

It is not uncommon for there to be several painful areas that are seemingly unrelated. However, with the advancing understanding of the neurobiology of pain, we know that there is a common thread that ties these problems together. This is termed central sensitisation and refers to adaptations within the nervous system that both amplify pain and reduce our natural ability to dampen sensitivity. The body areas that hurt can expand and involve a range of body systems, hence why the pain can manifest in different regions and organs. The pain is an expression of this underlying sensitivity that needs to be targeted at a nervous system-immune system-endocrine system level as well as addressing the health of the body tissues. We use a contemporary and neuroscience-based programme of treatment, training and coaching to tackle the problem of pain, focusing upon the inter-related dimensions of pain: physical-cognitive-emotional.

Working closely with leading gynaecologists and gastroenterologists in Harley Street, you will have a detailed assessment that includes diagnostics as indicated, a full explanation of the nature of the pain and symptoms (pain education) and a comprehensive treatment programme designed for you. 

How do we treat these problems?

A pathological or structural basis for pain only explains part of the problem or in some cases not at all. It is the adaptations within body systems that create the pain experience to which we respond in thought and action. Whilst acute pain serves a vital survival purpose, drawing our attention to a body region that needs protecting for healing, a persisting pain becomes increasingly about the neuroimmune system and endocrine system responses. Pain certainly emerges from the body yet there is an underpinning correlate of activity within a vast network of brain cells that actually drives the experience. This network monitors the activity in the body systems and responds according to need. The response can be protective when the brain perceives the body to be in potential danger and includes pain, changes in movement and a range of other actions. In the early stages of a condition this is useful and adaptive, however if these responses continue beyond a useful time they themselves must be targeted alongside body nourishing strategies.

How can we target these systems? In an integrated manner, these systems can be re-trained with a range of sensorimotor techniques, specific exercises designed to restore a normal sense of the body and movement, strategies to deal with stress and anxiety that both affect the body systems, techniques for the progression of day to day living (work, home, sports), and general activity and exercise with confidence. Interlaced with these strategies, pain education (reduce the threat by developing your understanding of pain and the body’s ability to change), mindfulness-based stress reduction, focused attention training, resilience, coping and motivational skills, are used to optimise outcomes that are based upon improving your quality of life, sense of wellness and performance.

For further information, to book an appointment or to refer a patient please call us on 07932 689081


Fibromyalgia and the autonomic nervous system

Several recent papers have looked at the autonomic nervous system in fibromyalgia – see below

Clin Physiol Funct Imaging. 2013 Mar;33(2):83-91. doi: 10.1111/cpf.12000. Epub 2012 Nov 4.

Autonomic nervous system profile in fibromyalgia patients and its modulation by exercise: a mini review.

Kulshreshtha P, Deepak KK.

This review imparts an impressionistic tone to our current understanding of autonomic nervous system abnormalities in fibromyalgia. In the wake of symptoms present in patients with fibromyalgia (FM), autonomic dysfunction seems plausible in fibromyalgia. A popular notion is that of a relentless sympathetic hyperactivity and hyporeactivity based on heart rate variability (HRV) analyses and responses to various physiological stimuli. However, some exactly opposite findings suggesting normal/hypersympathetic reactivity in patients with fibromyalgia do exist. This heterogeneous picture along with multiple comorbidities accounts for the quantitative and qualitative differences in the degree of dysautonomia present in patients with FM. We contend that HRV changes in fibromyalgia may not actually represent increased cardiac sympathetic tone. Normal muscle sympathetic nerve activity (MSNA) and normal autonomic reactivity tests in patients with fibromyalgia suggest defective vascular end organ in fibromyalgia. Previously, we proposed a model linking deconditioning with physical inactivity resulting from widespread pain in patients with fibromyalgia. Deconditioning also modulates the autonomic nervous system (high sympathetic tone and a low parasympathetic tone). A high peripheral sympathetic tone causes regional ischaemia, which in turn results in widespread pain. Thus, vascular dysregulation and hypoperfusion in patients with FM give rise to ischaemic pain leading to physical inactivity. Microvascular abnormalities are also found in patients with FM. Therapeutic interventions (e.g. exercise) that result in vasodilatation and favourable autonomic alterations have proven to be effective. In this review, we focus on the vascular end organ in patients with fibromyalgia in particular and its modulation by exercise in general.


Clin Auton Res. 2012 Jun;22(3):117-22. doi: 10.1007/s10286-011-0150-6. Epub 2011 Oct 25.

A comprehensive study of autonomic dysfunction in the fibromyalgia patients.

Kulshreshtha P, Gupta R, Yadav RK, Bijlani RL, Deepak KK.



The hypothesis of autonomic nervous system involvement in pathophysiology in the patients with fibromyalgia has been addressed and tested time and again but the existing reports are both contradictory and inconclusive. A complete knowledge of the degree of autonomic dysfunction in fibromyalgia patients would be more substantial. We conducted a comprehensive non-invasive study to investigate the complete autonomic profile of female patients with fibromyalgia.


An autonomic function test using a standard battery and heart rate variability analysis in the 42 fibromyalgia patients as well as 42 age matched healthy controls was performed. Both autonomic activity (tone) and reactivity were measured. Autonomic tone (both time and frequency domain parameters) was measured using heart rate variability (HRV) analysis. Autonomic reactivity was measured using a standard battery of autonomic function tests.


Resting blood pressure (both systolic and diastolic) was significantly higher in the fibromyalgia patients than controls. The time domain variables and HF% as recorded by HRV were significantly lower in the patients than the controls. The autonomic reactivity for sympathetic and parasympathetic nervous system was found to be within normal limits.


The cardiac autonomic function is normal and the autonomic reflex arc seems to be intact in the patients with fibromyalgia.


It seems that ANS function may be normal in fibromyalgia. Of course there are many other factors to consider including the role of the immune system, central sensitisation, the endocrine system and the effects of stress.

In common with other persisting pain problems, fibromyalgia is a multidimensional and multisystem condition and must be addressed as such. Exercise has a role in that we need movement and exertion at an appropriate level for normal health. Of course any physical activity must be organised, planned and be titrated to the individual, similar to a drug. There must also be confidence in the activity and coping skills for the effects of exercise to deal with hypervigilance and catastrophising that often feature.

Fibromyalgia is a functional pain syndrome. Often in the clinic we see individual’s with more that one functional pain, for example pelvic pain, dysmennorhoea, IBS, migraine, bladder dysfunction and TMJ pain. We address these problems at source by using strategies that target the pain mechanisms and address the physical-cognitive-emotional factors that are integral to fibromyalgia and other enduring pain states.

RS – Specialist Pain Physio Clinics, London


Women and pain | Part 1


‘As many as 50 million American women live with one or more neglected and poorly understood chronic pain conditions’ 

Generally I see more female patients than male. This observation supports the view that chronic pain is more prevalent in women than in men for some conditions – see the International Association for the Study of Pain fact sheet here. There are some ideas as to why this may be, including the role of the sex hormones and psychosocial factors such as emotion, coping strategies and roles in life. Additionally, experimental studies have shown that women have lower pain thresholds (this is a physiological reading) and tolerance to a range of pain stimuli when compared to men although this does not clarify that women actually feel more pain – see here. Pain is a subjective experience of course, and modulated by many factors.

A campaign for women’s pain | Chronic pain in women (2010) report

It is not uncommon for a female patient to tell me about her back pain and continue the narrative towards other body areas that hurt and cause problems. This may include pelvic pain, migraine, headache, irritable bowel syndrome, chronic knee pain, widespread sensitivity and gynaecological problems (including dysmenorrhoea, endometriosis and difficulty conceiving). These seemingly varied conditions are typically looked after by a range of medical and surgical disciplines: gynaecology, neurology, rheumatology, gastroenterology and orthopaedics. More recent science and thinking has started to join the dots on these problems, offering new insight into the underpinning mechanisms and more importantly approaches that can affect all the conditions in a positive way. This is certainly my thinking on this hugely significant matter.

Reconceptualising pain

Undoubtedly pain is complex. This is particularly the case when pain persists, disrupting and impacting upon life. Reconceptualising pain according to modern neuroscience is making a real difference to how we think and treat pain – see this video. Briefly, thinking of pain as an output from the brain as a result of a complex interaction of circumstance, biology, thought, emotion and memory begins to give an insight into the workings of the brain and body. Pain is individual, it is in the ‘now’ but so coloured by the past and what it may mean to the individual. The context or situation in which the pain arises is so very important. We talk about pain from the brain but of course we really feel it in our physical bodies, but the location is where the brain is projecting the sensation – see this video.

Neuroscience has shown us that the danger signals from the body tissues are significantly modulated by the brain before the end output is experienced. Factors that influence the messages include attention, expectation and the circustance in which the individual finds herself. We have powerful mechanisms that can both facilitate and inhibit the flow of these signals and these reside within the brain and brain stem. For this reason we must consider the person’s situation, their expectations, hopes, goals, past experiences and current difficulties, and how these can affect their current pain.

Stress & emotion

Any hugely emotive issue within someone’s life can impact enormously upon pain and sensitivity. This can be the stress of a situation including caring for a relative, losing someone close, work related issues and divorce. The problem of conception certainly features in a number of cases that I see, causing stress and turmoil for both partners but clearly in different ways. Fertility receives a great deal of attention in the media and there are a many clinics offering treatment and therapies, in effect raising awareness and attention levels towards the problem. The pain caused by difficulties having children can manifest physically through the stress that is created by the situation. Thoughts, feeling and emotions are nerve impulses in the brain like any other and will trigger physical responses including tension. Stress physiology affects all body systems, for example the gastrointestinal system (e.g./ irritable bowel), nervous system (e.g. headaches, back pain) and the immune system (e.g. repeated infections).


Lifestyle factors play a significant role in persisting pain. Modern technology and habits that we form easily may not be helpful when we have a sensitive nervous system. For example, sedentary work, the light from computer screens, pressures at work, limited exercise, poor diet, binge drinking and smoking to name but a few. All are toxic in some way as can be our own thinking about ourselves. When we have a thought, and we have thousands each day, and we pay attention, becoming absorbed in the process, the brain reacts as if we are actually in that situation. Consequently we have physical and emotional responses that can be repeated over and over when we dwell on the same thinking. This is rumination and is likely due to ‘hyper-connectivity’ between certain brain areas – see here. We can challenge this in several ways including by changing our thinking and using mindfulness, both of which will alter brain activity and dampen these responses. It does take practice but the benefits are attainable for everyone.

In summary, the underlying factors that must be addressed are individual and both physical and psychological. Pain is complex and personal, potentially affecting many different areas of life. How we live our lives, what we think and how we feel are all highly relevant in the problem of pain as borne out of sensible thinking and the neuroscience of pain. Understanding the pain, learning strategies to reduce the impact, receiving treatment that targets the underlying mechanisms, making healthy changes to lifestyle and developing good habits alongside the contemporary brain based therapies can make a huge difference and provide a route forwards.

For information on our ‘join the dots’ treatment programmes for chronic pain, contact us here or call 07932 689081