Whole Body Pain

Whole Body Pain

Introduction

Whole body pain, often termed fibromyalgia, is associated with strong evidence of nerve dysfunction and damage on specialized questionnaires, specialized physical examination, electrical conduction testing and nerve on biopsy.  Given this information, it is probably best to describe fibromyalgia as an extensive small fiber neuropathy.  Here is the reference of a very well done scientific article on this topic.

Üçeyler N, Zeller D, Kahn AK, Kewenig S, Kittel-Schneider S, Schmid A, Casanova-Molla J, Reiners K, Sommer C.  Small fibre pathology in patients with fibromyalgia syndrome.   Brain. 2013 Jun;136(Pt 6):1857-67. doi: 10.1093/brain/awt053. Epub 2013 Mar 
 
Fibromyalgia syndrome is a clinically well-characterized chronic pain condition of high socio-economic impact. Although the pathophysiology is still unclear, there is increasing evidence for nervous system dysfunction in patients with fibromyalgia syndrome. In this case-control study we investigated function and morphology of small nerve fibres in 25 patients with fibromyalgia syndrome. Patients underwent comprehensive neurological and neurophysiological assessment. We examined small fibre function by quantitative sensory testing and pain-related evoked potentials, and quantified intraepidermal nerve fibre density and regenerating intraepidermal nerve fibres in skin punch biopsies of the lower leg and upper thigh. The results were compared with data from 10 patients with monopolar depression without pain and with healthy control subjects matched for age and gender. Neurological and standard neurophysiological examination was normal in all patients, excluding large fibre polyneuropathy. Patients with fibromyalgia syndrome had increased scores in neuropathic pain questionnaires compared with patients with depression and with control subjects (P < 0.001 each). Compared with control subjects, patients with fibromyalgia syndrome but not patients with depression had impaired small fibre function with increased cold and warm detection thresholds in quantitative sensory testing (P < 0.001). Investigation of pain-related evoked potentials revealed increased N1 latencies upon stimulation at the feet (P < 0.001) and reduced amplitudes of pain-related evoked potentials upon stimulation of face, hands and feet (P < 0.001) in patients with fibromyalgia syndrome compared to patients with depression and to control subjects, indicating abnormalities of small fibres or their central afferents. In skin biopsies total (P < 0.001) and regenerating intraepidermal nerve fibres (P < 0.01) at the lower leg and upper thigh were reduced in patients with fibromyalgia syndrome compared with control subjects. Accordingly, a reduction in dermal unmyelinated nerve fibre bundles was found in skin samples of patients with fibromyalgia syndrome compared with patients with depression and with healthy control subjects, whereas myelinated nerve fibres were spared. All three methods used support the concept of impaired small fibre function in patients with fibromyalgia syndrome, pointing towards a neuropathic nature of pain in fibromyalgia syndrome.
 
What Causes the Nerve Damage in Whole Body Pain? 
This is not clearly known. However research is pointing to Schwann Cells that help protect and repair nerves. There may be a failure of energy production in those Schwann cells that leads to a build up of toxins that cause nerves to stop working properly and become damaged.  A very good article was published this year in the journal Neuron. Again, the entire article is available from the journal Neuron, but here is the reference and a summary. 
 
Viader A, Sasaki Y, Kim S, Strickland A, Workman CS, Yang K, Gross RW, Milbrandt J. Aberrant Schwann cell lipid metabolism linked to mitochondrial deficits leads to axon degeneration and neuropathy.  Neuron. 2013 Mar 6;77(5):886-98. doi: 10.1016/j.neuron.2013.01.012.
 
Schwann cells surround neurons. Neurons are nerves cells that have a cell body and very long arms (axons) that conduct impulses from nerve to another.  These Schwann cells (SCs) critically support the long-term preservation and function of all peripheral nerve axons, as well as their repair after damage.  Schwann cells are powered by cell factories for energy called mitrochondria.  Genetic mutations of mitrochondria are being found. Interestingly, abnormal mitochondria in the nerves of patients with neuropathy often localize to SCs.  Mitochondrial dysfunction is thought to be largely responsible for the peripheral nerve deficits that afflict large numbers of people with diabetes.  To find out what "bad" or "energy deficient" mitochrondria do, the researchers studied mice with those type of mitrochondria.  They found that the SCs in these rats do not make normal fats (lipis) which they were "sick."  Instead, they burn fatty acids from elsewhere for fuel, and this led, among other things, to a build up of acylcarnitine. Acylcarnitine is toxic to nerves and resulted in damage to the damage of the axons (nerve processes) of these nerves.
 
So what do we do with this information? 
We educate patients with whole body pain that the pain is "not in their head."  Instead, they likely have nerve damage of small nerves that is called a small fiber neuropathy.  However, biopsy of nerves is not commonly done other than for research.  It is also important to be aware of the importance of SCs and things that can either help or hinder their function, since they, in turn, are responsible for the health of nerves.  We need to keep alert for scientific literature that explains more completely how SCs work and how nerves get damaged.  In addition, we need to ask how dextrose or mannitol injection or platelet rich plasma may favorably affect SC function.  We clearly observe clinical benefit but we can likely help more if we can truly understand how it works.  Notice that the TRPV1 channel on nerves determines if they cause pain and if the nerve produce healthy and degenerative proteins.  It will be important to see how the SC function relates to the status of the TRPV1 receptor.
 
In other words, we are getting closer to an answer.  We need to keep our thinking cap on. 
 
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K. Dean Reeves, M.D. is a physician and medical researcher in the area of pain caused by arthritis, chronic sprains and chronic strains. His private practice is located in the greater Kansas City area of Roeland Park, Kansas.  He collaborates in research with other locations across the country and internationally, and is licensed in the states of Kansas and Missouri.

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Dr. K. Dean Reeves

No part of this site should be understood to be personal medical advice or instruction in how to perform injection therapy. A decision on treatment requires a good history and full examination and a knowledge of your treatment goals. Treatment decisions should be made in consultation with your personal healthcare professional and/or prolotherapist.