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.

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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.

Abstract

OBJECTIVES:

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.

METHOD:

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.

RESULTS:

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.

INTERPRETATION:

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

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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

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