Something I wrote a few years ago.
Why Do I Hurt Everywhere? Dr. Michael C. Raucci
The hallmark symptom of fibromyalgia is inexplicable chronic pain. The pain is often found over the majority of the body or the pain may appear to move. Often times certain areas will exhibit pain that is constant and more severe. Sometimes patients will present to their doctors with bizarre symptoms such as pain on only one side of the body (from head to toe) or pain that moves from place to place on a daily basis. These presentations are baffling to most doctors and all too often patients are told that these pains are all in their heads. (Translation: The doctor thinks they are crazy). The doctor who comes to this conclusion is both right and wrong. By stating that the problem is all in the patient's head the doctor is correct. Unfortunately, the doctor who makes this uninformed diagnosis assumes that the patient's problem is psychological when in fact, it is physiological. The problem is produced by neurochemical aberrations in the brain. The condition fibromyalgia is a real, physiological problem. The reason the diagnosis has been so slighted over the past decade is the failure of clinicians to recognize this fact. The typical doctor examines all the aches and pains in the person's body and correctly concludes that there is nothing wrong with those structures and the patient's unusual distribution of pains fits no known disorders. They don't even consider the possibility that it could be a central disorder (coming from the brain).
Fibromyalgia is caused by varying degrees of the four related phenomena listed below.
1) Reduced Serotonin Effectiveness
2) Central Sensitization
3) Peripheral Sensitization
4) Psychosomatic Overlay
Before delving into what these are, it is important to understand exactly what pain is.
In the battle of Santa Cruz, Lord Nelson lost his right arm. Many years later, he experienced pain in the arm which no longer existed (phantom pain). The emergence of these sensations led (Nelson) to proclaim that he now had direct proof for the existence of the soul. For if an arm can survive physical annihilation, why not the whole person? (Ramachandran, 2000)
This anecdote helps to preface a discussion on the brain because it describes a basic tenet of pain. Pain is a function of the brain and it occurs solely in the brain. Lord Nelson left his arm on the battle field. After the battle, if one of Lord Nelson's enemies had stabbed the dismembered arm with his spear in disgust, would Lord Nelson, now miles away have felt any new pain? Of course not. The dismembered arm itself experiences no pain. The unattached arm lacks the ability of perception.
Most amputees experience something called phantom limb pain. It is the perception of pain in the limb that no longer exists. The amputee feels this pain as real as they would pain in their other remaining limbs. But why? Mapped onto our brains is an exact map of our bodies. The relative size of the parts are distorted but every anatomical part which has the ability to perceive pain is represented. When Lord Nelson lost his right arm or when an amputee has his leg removed, the portion of the brain which was mapped for those parts remains intact. Given the right conditions, the neurons in that part of the brain may become excited and the person will feel pain in a nonexistent limb.
How does pain normally occur? We have already identified that pain occurs solely in the brain but clearly something is happening outside the brain. In order to understand the process we need to define a word: Nociception - the neurochemical recognition of tissue injury. When I cut the tip of my left index finger, what is the chronological cascade of events:
1) Cellular membranes are cut
2) Chemicals leak out of those cells
3) Some of those chemicals stimulate nociceptive receptors in the area (nociceptors are receptors that recognize tissue injury and transmit that information to nerves)
4) A neurologic signal is transmitted along a nerve out of the finger, up through the hand, up the arm, into the spinal cord at the level of the neck, and up into the brain into the exact area which represents the tip of my left index finger
5) My brain interprets the information
6) I perceive pain in the tip of my left index finger. I never feel any pain until step 6. If the process is interrupted prior to step 6, I will not feel pain at all.
Reduced Serotonin Effectiveness
Serotonin is the wonder hormone of the brain. When present in normal amounts, it suppresses pain, removes depressive symptoms, and helps to provide complete, rejuvenating sleep. When it is lowered it results in enhanced pain perception, depression, and poor, non-restorative sleep. Some studies have shown some fibromyalgia sufferers have lower than normal amounts of serotonin within the central nervous system (the brain and spinal cord). This finding alone would help to describe the major symptoms of fibromyalgia, however other fibromyalgia sufferers have normal amounts of serotonin. It would appear that in these individuals it is not that they have too little serotonin in the brain but that their serotonin utilization system is not functioning optimally; reduced serotonin effectiveness. Why does this increase the amount of pain? We have already discussed the concept of nociception and tissue injury but there is another aspect of nociception yet unexplained. There are low levels of nociceptive transmission which occur in all people continuously and without tissue injury. All of our nociceptive nerves are sending these baseline transmissions every hour of every day. Normally, when these low level transmissions reach the central nervous system, serotonin and other hormones (endorphins and enkephalins) suppress them below our brains ability to recognize them Thus there is no perception of pain. The reason why anti-depressants are often used to treat fibromyalgia is because they enhance the effectiveness of serotonin. Unfortunately, this has not shown long term effectiveness in the majority of patients.
Peripheral Sensitization
Peripheral means outside of the central nervous system - For our purposes, the rest of the body. Peripheral sensitization occurs to an area of injury when that area's nerve receptors become so irritated that they spontaneously depolarize, sending nociceptive signals to the brain in the absence of any irritation or in the presence of a normally sub-threshold irritation (such as the touch of ones clothes against the skin). This might also be called peripheral hypersensitivity. When this is present, abnormally intense signals are sent to the brain in the absence of a similarly gauged stimulus resulting in the experience of intense pain for no apparent reason. Peripheral sensitization usually occurs only in areas where there was an initial injury. It may spread to adjacent anatomical structures but usually will not spread across the entire body from the site of initial injury. In some fibromyalgia patients, peripheral sensitization will develop over a long period of time in uninjured areas because of a feedback loop from the central nervous system to the periphery after central sensitization has set in.
Central Sensitization
Central sensitization is the process described by Lord Nelson in the aforementioned story. The process by which central sensitization begins varies from person to person. It can begin with a continuous flow of nociception from the periphery, or from a direct physiologic/chemical change at the level of the brain. In either case, an area of the brain, which represents the mapped portion of a part of the body becomes sensitized to pain. Assume its the area representative of the lower back. That area of the brain becomes so sensitive that it no longer requires any nociceptive input from the periphery to create the perception of pain. What begins to happen is the person begins to feel pain in their back when there has been no injury to the back and there are no suprathreshold nociceptive signals being sent. The entire pain phenomena occurs in the brain. The person perceives the pain to be in their back because that is the area of the brain which is engaged in this central self excitation. This phenomena is common to all sufferers of chronic pain, including those with disc herniations an severe soft tissue injuries. What is unique to fibromyalgia is that the area of central sensitization on the brain grows or spreads to include other areas, so that suddenly the person may awaken with pain in their leg despite the fact that they suffered no injury there. It is self excitation of a representative area of the brain which is injured in the periphery which makes fibromyalgia unique. The theory of central sensitization helps to describe those otherwise bizarre findings, such as pain on one entire side of the body and pain that seems to move and change.
Psychosomatic Overlays
Psychosomatosis is the psychological creation of pain. It also occurs solely at the level of the brain and probably involves many of the same neurochemicals but its can be managed with psychotherapy or counseling. When a person feels there is no hope or feels depressed physical symptoms can become enhanced because of psychological overlays. Psychosomatosis by itself is not fibromyalgia. A distinction must be drawn so that person's can be directed towards proper treatment. Psychosomatosis, however, becomes a part of the fibromyalgia condition because of the stress, anxiety and depression associated with chronic pain.
Monday, June 29, 2009
Sunday, June 21, 2009
healthcare reform
Recently President Obama proposed new health care reform that would include some government control or participation. One of President Obama’s proposals is the creation of a government insurance company that will compete with private insurers. This suggests that a government insurance option will drive private health insurance premiums down by creating competition. Responses from legislators have been emotionally charged and influenced strongly by large lobbying groups. Senator Richard Shelby stated that acting on the President’s proposal would be “the first step in destroying the best health-care system the world has ever known," while other pundits have lamented that it would put bureaucrats between patients and their doctors.
While I don’t dispute that the United States offers the finest health care in the world, it does not do so for every citizen. The slogan of those that seek to protect the status quo should be modified to say “the United States offers the finest healthcare in the world to those who can afford it.”
The current system is fatally flawed as each year it is capable of providing health care coverage to fewer and fewer Americans. Health insurance premiums have been rising at 5 times the rate of inflation. It is a system that is regulated by corporate profit margins not by science and compassion. This system places unnecessary stress on caregivers by allowing third party payers to shake down doctors, hospitals and patients under the guise of managing healthcare. And finally, it is a system that depends upon other programs such as Medicaid and Medicare to care for those that can’t afford its lofty premiums. In the current health insurance system almost 45% of poor adults are uninsured (poor being defined as those who earn <200% of the poverty level).
In a compromise the President suggests that we not throw the baby out with the bathwater. He proposes, and I believe rightfully so, that by maintaining the current system and infusing some government control in the form of a government based insurance option we can transition towards a more equitable system which allows all US citizens to have access to basic health services. Some would say that healthcare is not a right but is a privilege which must be paid for. In the past this was true but as healthcare has progressed towards certain scientific certainties members of our population are all too frequently presented with the dilemma, “If you can pay for this procedure or medication you will live and if you cannot you will die.” As our society evolves, so do our perceptions of fairness. I believe that at this stage in our societal evolution the expectation of basic medical services should be as much a right as the right to vote. For those that seek elevated levels of coverage above what the national discussion determines to be basic, private insurances will no doubt provide options. The current stratified system is insufficient and unfair. Those who fall below a preset poverty level receive Medicaid (a service which varies from state to state), those who work lower paying jobs but whose incomes exceed the poverty set point often have no coverage and those with higher paying jobs enjoy the security of more comprehensive insurance. In addition, those with pre-existing injuries and diseases often lose coverage when changing jobs.
There is no perfect system and countries in Europe and Canada that have nationalized healthcare have learned that their systems are also flawed but at least medical care is available to all citizens. Current estimates put the number of uninsured Americans at approximately 50 million, a number that is sure to rise as unemployment rates increase across the country.
The real question when it comes to healthcare is, do we want a system that supplies top notch healthcare to only 65% of citizens, or do we want a system that insures all citizens at a basic level and allows for higher level coverage for those that wish to purchase it? It’s still a stratified system but at least there is no layer of non-coverage.
The ranks of the insured are reducing as small business owners choose to go without insurance because they can’t afford it, employers with shrinking bottom lines put more and more financial responsibility to pay for health insurance on their employees, and as the weakened economy stretches the unemployment roles many unemployed individuals must choose between making their rent or mortgage payments and paying for COBRA plans which exceed their unemployment benefits.
I don’t know if the time for change is now. Given our current economic woes, the housing crisis, the collapse of the financial system, our role in two foreign wars, impending double digit unemployment and a national debt that recently exceeded the number of available digits on the Times Square clock designed to measure it, it seems an inopportune time. But as so often occurs, difficult decisions are often thrust upon us when we least want to deal with them. I do not know where the money will come from. I am not sure how to structure a system that would provide quality care without exclusion that would still properly compensate doctors, nurses, and other healthcare providers. I do not know… But I do know that we cannot continue to allow a dwindling few to utilize healthcare resources while friends and neighbors wallow in the unknowns of being uninsured. I do know that debating this can’t be anything but good. I do know that we have intelligent actuaries, statisticians, healthcare providers, administrators, and politicians who can solve this problem.
The president’s proposal, while no doubt a stop-gap measure on what is likely a slow march toward nationalized healthcare is a reasonable point to begin the national debate. As evidenced by Congressional Budget Office estimates the Obama plan would be costly and it most certainly could not be implemented without breaking Obama’s pledge to not raise taxes on the middle class. So let the debate begin.
It has been said that the truest measure of a society is how it treats those in the most need. What does it say about the country with the “greatest healthcare system the world has ever known” when we only allow the wealthiest and most privileged to utilize it?
Dr. Michael Raucci
While I don’t dispute that the United States offers the finest health care in the world, it does not do so for every citizen. The slogan of those that seek to protect the status quo should be modified to say “the United States offers the finest healthcare in the world to those who can afford it.”
The current system is fatally flawed as each year it is capable of providing health care coverage to fewer and fewer Americans. Health insurance premiums have been rising at 5 times the rate of inflation. It is a system that is regulated by corporate profit margins not by science and compassion. This system places unnecessary stress on caregivers by allowing third party payers to shake down doctors, hospitals and patients under the guise of managing healthcare. And finally, it is a system that depends upon other programs such as Medicaid and Medicare to care for those that can’t afford its lofty premiums. In the current health insurance system almost 45% of poor adults are uninsured (poor being defined as those who earn <200% of the poverty level).
In a compromise the President suggests that we not throw the baby out with the bathwater. He proposes, and I believe rightfully so, that by maintaining the current system and infusing some government control in the form of a government based insurance option we can transition towards a more equitable system which allows all US citizens to have access to basic health services. Some would say that healthcare is not a right but is a privilege which must be paid for. In the past this was true but as healthcare has progressed towards certain scientific certainties members of our population are all too frequently presented with the dilemma, “If you can pay for this procedure or medication you will live and if you cannot you will die.” As our society evolves, so do our perceptions of fairness. I believe that at this stage in our societal evolution the expectation of basic medical services should be as much a right as the right to vote. For those that seek elevated levels of coverage above what the national discussion determines to be basic, private insurances will no doubt provide options. The current stratified system is insufficient and unfair. Those who fall below a preset poverty level receive Medicaid (a service which varies from state to state), those who work lower paying jobs but whose incomes exceed the poverty set point often have no coverage and those with higher paying jobs enjoy the security of more comprehensive insurance. In addition, those with pre-existing injuries and diseases often lose coverage when changing jobs.
There is no perfect system and countries in Europe and Canada that have nationalized healthcare have learned that their systems are also flawed but at least medical care is available to all citizens. Current estimates put the number of uninsured Americans at approximately 50 million, a number that is sure to rise as unemployment rates increase across the country.
The real question when it comes to healthcare is, do we want a system that supplies top notch healthcare to only 65% of citizens, or do we want a system that insures all citizens at a basic level and allows for higher level coverage for those that wish to purchase it? It’s still a stratified system but at least there is no layer of non-coverage.
The ranks of the insured are reducing as small business owners choose to go without insurance because they can’t afford it, employers with shrinking bottom lines put more and more financial responsibility to pay for health insurance on their employees, and as the weakened economy stretches the unemployment roles many unemployed individuals must choose between making their rent or mortgage payments and paying for COBRA plans which exceed their unemployment benefits.
I don’t know if the time for change is now. Given our current economic woes, the housing crisis, the collapse of the financial system, our role in two foreign wars, impending double digit unemployment and a national debt that recently exceeded the number of available digits on the Times Square clock designed to measure it, it seems an inopportune time. But as so often occurs, difficult decisions are often thrust upon us when we least want to deal with them. I do not know where the money will come from. I am not sure how to structure a system that would provide quality care without exclusion that would still properly compensate doctors, nurses, and other healthcare providers. I do not know… But I do know that we cannot continue to allow a dwindling few to utilize healthcare resources while friends and neighbors wallow in the unknowns of being uninsured. I do know that debating this can’t be anything but good. I do know that we have intelligent actuaries, statisticians, healthcare providers, administrators, and politicians who can solve this problem.
The president’s proposal, while no doubt a stop-gap measure on what is likely a slow march toward nationalized healthcare is a reasonable point to begin the national debate. As evidenced by Congressional Budget Office estimates the Obama plan would be costly and it most certainly could not be implemented without breaking Obama’s pledge to not raise taxes on the middle class. So let the debate begin.
It has been said that the truest measure of a society is how it treats those in the most need. What does it say about the country with the “greatest healthcare system the world has ever known” when we only allow the wealthiest and most privileged to utilize it?
Dr. Michael Raucci
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