Stress and Fybromyalgia

In my parents kitchen for the past several years, they have had a cast iron sign spelling the word “Relax.” My mother has fibromyalgia and has struggled with chronic pain for many years. Maybe she put up the sign following an inner intuition that told her relaxation would be the key for her to feel better. A few years ago I started teaching Yoga sessions for my mother along with my other immediate family members. We've had better days, and worse days, with the pain management. The key seems to be finding ways to relax, and to relieve the hold that stress has on her body.

Stress plays a huge part in so many illnesses and ailments. In fact, stress has been estimated as being a cause, or related factor in 80 percent of illnesses (McIlwain, 1999, p90). Yogis have practiced asana, pranayama, and meditation techniques for centuries, helping them relieve stress and stay healthy and pain free. The stress response and GAS (General Adaptation Syndrome) as coined by Hans Selye (free dictionary.com), have a major impact on fibromyalgia and chronic pain. Stressors keep people in a place where pain is felt more strongly, so finding ways to relieve stress can help reduce, and even prevent, painful episodes. Yoga techniques such as pranayama, meditation, and gentle asana can help reduce the stress response and bring individuals into the relaxation response where there can be relief to stress, and pain.

The Stress Response

Stress is not always as bad as we might believe. The physiological stress responses are a well adapted part of human functioning. The human body's reaction to stress is meant to keep us safe and alive. The body is constantly checking in to ask the question “Am I safe?”. When the answer to that question becomes “no!” the stress response kicks in. Sometimes known as the fight-or-flight response, our perception of danger jolts the sympathetic nervous system into high gear (Clampett, 2009, p18). Let's say you are walking through the woods alone. You hear a rustle in the bushes. Your heart starts to beat a little bit faster as you assess the situation. If it turns out to be a humming bird flying off it's perch, you sigh, you are safe, the stress response fades. If it turns out to be a hungry, angry wolf who jumps out growling at you fight-or-flight ramps up. The stress response is there to help you keep safe in this dangerous situation.

All of our internal systems are regulated by the nervous system. Ideally we exist in a state of balance or homeostasis. The Autonomic Nervous System controls all of the automatic functions of the body such as the heartbeat, digestion, and, most of the time, breathing. The Autonomic Nervous System has two parts, the Sympathetic Nervous System (SNS) and the Parasympathetic Nervous System (PNS). When these two are out of balance havoc ensues. The SNS responds to stress and gives us the “fight-or-flight” response, while the PNS holds the relaxation response. When we live in a prolonged place of stress, as many of us do in our modernized world, the SNS can be overworked and overtaxed, leading to exhaustion, burnout, and contributing to many illnesses, including fibromyalgia.

When the wolf jumped out to attack us he set the body's stress response (the SNS) in motion. Physiologically a lot of things happen at the onset of the stress response. We enter the first stage of GAS (General adaptation syndrome), the alarm stage (stress response.net)(holistic online.com). Stress hormones are dumped into the bloodstream, the heart rate rises, blood pressure rises as blood vessels constrict. The body is on high alert ready to pump oxygen and adrenaline - preparing for action. Breath rate increases, as the bronchial tubes dilate to help increase blood oxygenation. Energy stored in the liver is converted into fuel for strength and stamina (Clampett, 2009 p20-21)(Cuda, 2010). The body is priming itself to deal with the danger of the wolf. Will you run, or will you fight? Either way, the muscles tense up and glucose and fatty acids are mobilized to ready for quick action (Clampett, 2009, p20). You are ready to fight this wolf off, or run like the dickens to protect yourself. In this example all aspects of the the stress response help keep you safe from harm. But what happens when those stresses stay elevated for more than the needed short term safety response? What happens when we LIVE in our stress response?

Let's replace the wolf with an every day stressor like your boss, your family, traffic on the freeway, impending bills, world politics, the stock market, gasoline prices, grades at school, or any of the myriad of stresses we may face in life. With the wolf we either fight or run away, that stressor is resolved and the body systems drop back down to the baseline. Our daily stress does not get resolved as quickly. If it stays elevated long enough the nervous system becomes impaired (Cuda 2010)(Clampett, 2009, p.21). You are now moving into the 2^nd phase of GAS, the resistance stage. During the resistance stage baselines are re-set. In other words, rather than returning to a place of balance the body adapts to the stressors present and creates a new baseline. For example, your blood pressure might reset its baseline to something like 180 over 120 verses its normal baseline of 120 over 80 (Clampett, 2009). Through this re-set, we lose our energy and become more prone to get ill (stress response.net). Just imagine if that wolf were still chasing you 3 days later.

All of this leads to stage 3 of GAS: Exhaustion. You become weak, and more sensitive to stress. You are at risk for a host of illnesses, from heart disease and heart attack, to depression, sleep issues, bipolar disorder, and digestive problems such as Irritable Bowel Syndrome (IBS) (stress response.net) Your energy and immunity reserves are tapped and it seems as though the system is breaking down (holistic online.com). Were you still running from the wolf, this would be where you collapse from exhaustion and succumb to your fate.

Unfortunately, the stress response cannot tell the difference between the angry wolf and the angry boss. The physiological responses are the same whether it is an actual impending physical danger, or mental or emotional stress at work or at home. Both scenarios result in a reaction from the sympathetic nervous system and if fighting or fleeing are not options, we may end up living in the stress response (Clampett, 2009, p22). It may seem like there is no way out, especially once we reach the state of exhaustion, but there are ways to bring ourselves back into balance through Yoga. We will talk about how to calm the stress response later.

The Pain of Fibromyalgia

When I hear my mother talk about the pain and fatigue she feels through her fibromyalgia, I notice the parallels between those symptoms and some of the physiological stress reactions. The constant nagging pain and exhaustion, the stiff and sore muscles in the morning, and the emotional toll look a lot to me like someone who is living in an intense 3^rd stage (the exhaustion stage) of GAS. My intuition tells me that there is a link with stress causing or contributing her fibromyalgia.

The term fibromyalgia was coined in 1976 to describe a collection of symptoms including, chronic muscle pain, tenderness, fatigue, and tender points (McIlwain, 1999, p10). Fibromyalgia symptoms also include anxiety, IBS, chronic back pain, muscle stiffness, swelling or numbness in the extremities, depression or anger, mental malaise (fibro fog), and headaches. Of course, the primary symptom is pain, a flu like pain that can be severe and exists especially in the muscles, tendons and ligaments around the joints (McIlwain, 1999 p19-20)(Staud, 2007 p10-11). There are studies that link high amounts of psychological stress to the onset of fibromyalgia. There is potentially a biochemical reaction in the body to such stress, or even sudden trauma to the central nervous system (McIlwain, 1999 p16). There is also research to indicate that the spinal cord becomes overloaded with input in patients with chronic pain, making them potentially more sensitive. Even a simple stimulus may cause a pain reaction (McIlwain, 1999, p15).

Fibromyalgia has been difficult to diagnose, with many patients being told that the pain is all “in their head” (Williamson, 1998, p106) which would naturally lead to more fear and stress in the patient. It is not all “in the head”, but physical pain does have its root in the brain. Pain is the brain's perception of certain stimuli. There are pain sensors in the skin and organs that send signals to the brain, which processes the signals and pain is experienced (Payne, 2002, p204). Because the stress response keeps the body at high alert it is open for more pain to be felt. It is as though the brain and nervous system are just opening themselves to painful sensations (Payne, 2002, p204).

Pain is felt from an interpretation of the signals sent to the brain through ion channels in the nervous system. The more ion channels that are present, the more pain is felt. It is possible that this, along with a lack of pain relieving hormones in the system, could be the case in a fibromyalgia patient. There is also research suggesting the possibility of less blood flow to the parts of the brain that regulate pain, or a higher level of a brain chemical called substance P, a neuro-chemical with the purpose of sending pain messages to the body. Fibromyalgia sufferers have been found to have up to 3 times normal levels of substance P in their bodies (Staud, 2007 p48)(McIlwain, 1999 p15). In short, people with fibromyalgia feel pain faster, more intensely, and longer than others (Staud, 2007, p60). One of the confusions about the pain of fibromyalgia is the outsider's view that certain things should not hurt. For the fibromyalgia patient those sensations are real. The outsider sees a stimulus that is non-harming and says it should not be painful, but the fibromyalgia sufferer may be more sensitive to a pain response.

Stress appears to both contribute to, and come from fibromyalgia and the fibromyalgia pain. A patient on a 2-week long cruise started to sleep better and get relief from her symptoms during her vacation. Unfortunately the symptoms came back within a month of returning home (McIlwain, 1999 p18). This is evidence that stress contributes to fibromyalgia pain. In fact, stressing out can aggravate fibromyalgia symptoms. In a study done in 2001 in the Annals of Behavioral Medicine it was found that when compared to osteoarthritis patients, those with fibromyalgia had an increase in pain when presented with a stressful stimulus, whereas those with osteoarthritis did not (Staud, 2007, p178). While stress contributes to pain, being in pain is stressful. Pain causes emotional stress through fear, as well as physical stress through the reaction of the muscle. Muscles tense to protect the area receiving the painful stimulus (Williamson, 1998, p108), potentially increasing pain. The ramifications are cyclical.

Whether stress is a cause of, or just a contributor to fibromyalgia seems to be a grey area. Either way stress is a key factor (McIlwain, 1999, p90). Learning ways to mediate and lessen these stresses, and the body's reactions (the stress response), is a useful tool in managing the pain and other symptoms of fibromyalgia (Staud, 2007, p49).

The Relaxation Response

Relax. It's much easier said than done. Life in our modern world is filled with an unlimited number of stressors. It can be easy to get bogged down. It would be impossible and unnecessary to prevent every stressful stimulus in life. As we explored earlier, the stress response keeps us safe and alerts us to danger; however we need to find ways to balance the stress response effectively. We need to escape the continual sympathetic nervous system response of fight-or-flight, and learn to bring about the rest and relax reactions brought about by the parasympathetic nervous system.

In the 1960s Herbert Benson M.D. began to study the physical changes in metabolic rate, heart rate, blood pressure, etc. during the practice of Transcendental Meditation. He labeled these physical changes the “relaxation response.” The same results are also produced from other practices such as stretching, diaphragmatic breathing, and guided imagery. The relaxation response gets in touch with the PNS, and essentially turns down the fight-or-flight response (Clampett, 2009, p22).

Some of the effects of the relaxation response are a decrease in SNS activity, decreased heart and breath rates, increased digestive function, decreased muscle tension and blood pressure, and decreased anxiety (Clampett, 2009, p24). In particular, the decreased muscle tension and anxiety alone would be helpful to relieving the fibromyalgia symptoms of depression and stiff and sore muscles. If we can access the relaxation response, we can cut down the contributions of stress, and reduce pain and other fibromyalgia symptoms. I can see evidence of this in my Yoga sessions with my mother. She once told me that after a session of gentle Yoga asana and breath-work she feels better that day and the next. As the week wears on and stress starts to rear its ugly head, the symptoms begin to return.

Some research suggests that the daily stresses in life have a huge impact on a patients' fibromyalgia symptoms (McIlwain, 1999, p90). Finding ways to cope with daily stress becomes of paramount importance to help manage these symptoms. There are many techniques in Yoga that can help elicit the parasympathetic nervous system and take us into the relaxation response. Managing stress in this way can be a major help to those suffering with fibromyalgia.

Yoga Therapy Techniques to De-Stress and Calm Fibromyalgia

Yoga has many tools that can help to manage stress. As we have seen, stress is a major contributor to the symptoms of fibromyalgia, and regulating our daily stress can make a profound impact on how a fibromyalgia sufferer feels day to day. The following are a few tools Yoga has to help bring someone out of the sympathetic nervous system's fight-or-flight response and into the parasympathetic nervous system's relaxation response.

Breath

The breath is an important tool to connect us with the PNS and to de-stress the mind and body. The breath, unlike most body systems, can be controlled both by the autonomic nervous system (automatically) and by the somatic nervous system (conscious control). This is an important link when talking about stress and the ability to calm ourselves down into the relaxation response. By taking conscious control of the breath we can intentionally slow it down, helping to damper the stress response. When someone is in a stress response, one of the physiological changes is that the breath rate increases. This can be useful when we need quick exchange of oxygen into the blood to prepare to fight or flee, but, in daily life, persistent rapid breath can burn out the system. There are many pranayama or yogic breath techniques. Here are two that can bring us out of the SNS and into the PNS for a relaxation response.

Deep Breathing:

• Sit in a chair, or lay on the floor or a bed comfortably

• Bring awareness to the breath, letting the abdominal and chest muscles relax

• Keeping the body relaxed let the breath deepen

• Fill into the abdomen, rib cage, and chest slowly and with attention

• Exhale long and slow emptying the lungs

• Take 5-10 rounds

• Relax and let the breath come back to its own natural rhythm

   

Slow, deep breathing helps to stimulate the parasympathetic nervous system. The results of deep breathing are many. The release of stress hormones slows down, as does the heart rate. (Clampett, 2009)(Payne, 2002)(McIlwain, 1999, p125).

Belly Breath:

• Sit in a chair, or lay on the floor or a bed comfortably

• Bring awareness to the breath, letting the abdominal and chest muscles relax

• Keeping the body relaxed let the breath deepen

• Bring attention to the lowest part of the belly, maybe by bringing the hands to the abdomen

• Focus on filling into the belly with each inhale, and letting the abdomen rise

• Exhale long and slow emptying the lungs, feeling the belly draw back in

• Take 5-10 rounds

• Relax and let the breath come back to its own natural rhythm

   

Belly breath is another technique that aids in relaxation, as well as pain relief (Payne, 2002, p41). Belly breath brings focus to the breath and helps to calm the mind. It also helps to expand the lowest part of the lungs where there is more blood flow, allowing for more oxygenation of the blood (Clampett, 2009, p132). Focusing on deep breathing, letting the lower abdomen expand on the inhales, helps to access the relaxation response. Also, lengthening the exhalations helps illicit the relaxation response.

There are many other, and more advanced pranayama techniques, but deep breathing and belly breath are a great way to start, especially with someone who is having severe fibromyalgia symptoms. Using these techniques can be a good first step in connecting the individual with the PNS, creating the relaxation response, and easing up fibromyalgia symptoms.

Meditation/Visualization

Meditation has been a part of Yoga practice for centuries. In the medical community meditation and visualization are finally being studied for their healing benefits. Because, it is a powerful tool to de-stress the mind and body, and to reduce pain (Payne, 2002, p55) it is extremely beneficial for fibromyalgia patients. Meditation is a powerful stress reliever that has been studied in fibromyalgia patients and shown to aid in the lowering of pain levels, improving sleep, and lowering depression levels (McIlwain, 1999, p124)(Staud, 2007, p187).

There are numerous ways and techniques to meditate. In fact, the focused breath technique in the last section is a form of meditating. Focusing on a word, or image, or sound, is also a great way to push aside the stress of the world and come into yourself.

Visualizing specific imagery has been shown to create a physiological response. For example, a group that was guided to imagine a fresh-cut lemon began to salivate; when imagining a beach on a warm day, heart rates and respiration began to slow down (Clampett, 2009, p155). This can be very helpful in countering the stress and symptoms fibromyalgia patients experience. Visualizations such as seeing themselves pain free, seeing a healing light flowing into and through their body, or picturing themselves in a peaceful and calming place (like the warm beach) help to reduce stress levels. Choosing visualizations that the patient can connect with is important, as these will help the patient relax more completely. The mind and body are fully interconnected. What influences one, pervades into the other. Meditation and visualization can help to de-stress the mind and therefore relax the body, leading a fibromyalgia sufferer out of the SNS stress response, and into a place of healing.

Asana

A patient with fibromyalgia may be afraid to move or exercise. My mother has days when she just does not want to get up and into our Yoga session, but every time, once we are through, she feels much more relaxed, and better overall. The fear that pain brings can keep someone static, but it is a common mistake in people with fibromyalgia to not stretch or exercise daily (Staud, 2007, p60).

Asana for a patient with fibromyalgia should progress slowly and with as little pain as possible. Pain creates stress, and stress creates pain. If someone forces too far or too quickly into any Yoga asana, they may create more stress and pain. The key is to move into the poses with breath and focus. Restorative and therapeutic practices are beneficial for this reason. These slow and rejuvenating practices should be stress free, and create a healing environment, thus holding the space for the person to heal on the inside (Clampett, 2009).

It is important to start slowly and build any asana program (Staud, 2007 p187). It is also important to avoid postures and movements that create more pain. The brain and body must re-learn how to work together, and that movement can take place without pain. When my mom tries to force herself saying “I just have to do it”, I notice her face contorts more, she gets discouraged, and her sessions aren't as effective, in essence she has gone back into the stress response. When she moves mindfully, slowly, with intention, and stays well back from her edges, she can more easily find a place of calm, allowing the de-stressing to take place. Whether simple movements to help stretch the body, or soft restorative poses to create an environment of healing, asana practice can be a powerful tool to help move into the PNS relaxation response and help in reducing stress and pain.

_______________

I have seen my mother's fibromyalgia symptoms increase in times of stress, and decrease due to practicing Yoga. Looking up at the simple word “relax” in her kitchen, I know that she intuitively knew the power her stress had over her fibromyalgia symptoms. Through our practice together, I know that using the Yoga techniques of pranayama, meditation, and simple asana are helping her to reduce stress and feel better. It is not a path without its speed bumps, and it comes in baby steps. On my first day studying Yoga Therapy RX at Loyola Marrymount University, our teacher, Larry Payne, talked about vinyasa krama, the concept of slow progression with step-by-step movement. If I've learned one thing through my studies, and one-on-one experience, this is so true when dealing with fibromyalgia. Life is never free of stress, nor should it be, but we can use these tools to regulate stress, and reduce the symptoms associated with fibromyalgia.

Bibliography

Clampett, Cheri, and Mithoefer, Biff. The Therapeutic Yoga Kit. Rochester: Healing Arts Press. 2009

Cuda, Gretchen. Just Breathe: Body Has A Built-In Stress Reliever. NPR, December 6, 2010, May 25 2011. < http://www.npr.org/2010/12/06/131734718/just-breathe-body-has-a-built-in-stress-reliever>

McIlwain, Harris H., and Bruce, Debra Fulghum. The Fibromyalgia Handbook. New York: Henry Holt and Company Inc., 1996-1999

Payne, Larry, and Usatine, Richard. Yoga RX. New York: Broadway Books, 2002

Staud, Robert, with Adamec, Christine. Fibromyalgia for Dummies. Indianapolis: Wiley Publishing Inc., 2007

Williamson, Miryam Ehrlich. The Fibromyalgia Relief Book. New York: Walker Publishing Company, Inc., 1998.

General Adaptation Syndrome. The Free Dictionary. < http://medical-dictionary.thefreedictionary.com/general+adaptation+syndrome>

Our Body's Reaction to Stress (General Adaptation Syndrome (GAS)). Holistic online.com. < http://www.holisticonline.com/stress/stress_GAS.htm>

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