Fibromyalgia Vortex Theory, The
“Vortex theory” is the author’s term.
The vortex theory is a hybrid between the psychogenic theory and the hypnogenic (sleep disorder induced theory).
The word “vortex” here is used as a metaphor for a powerful destructive mass of “swirling” or interacting negative factors that drag the whole person down. This creates something like the downward pull of a water whirlpool in rapids or going down a drain. This metaphor is used here to capture a number of key features of fibromyalgia. It is also a tool to help patients understand where the author believes problem lies and what needs to be done about it. The spinning of a vortex is a cyclical. According to the theory, fibromyalgia has at least three vicious cycles. They all serve to precipitate and exacerbate fibromyalgia attacks.
In my many cases I have found that this is a common onset pattern of for fibromyalgia. Many cases are triggered by an event such as a major or minor car accident or fall, then over time they ‘tumble’ into a pattern of 3 or more mutually reinforcing damaging factors which especially include bad sleep, worry and pain. Because (as I have seen many, many times) each of these three main factors aggravates the other the patent gets caught-up in a “storm” which can be thought of in severe cases as a constantly changing, swirling mess.
Author’s opinion on the benefits of the vortex theory as a treatment and motivation tool for patients
Modern medicine tends to focus on highly technical discoveries. This situation is different. I have come to believe that the vortex theory is one of the most powerful tools available to treat our patients. I do not believe that any drug or combination of drugs will ever cure fibromyalgia. The vortex theory a “low tech” theory that I found my patients could relate to. Furthermore, they often readily admitted the operation of the three vicious cycles in themselves. Reform takes mental work. This work requires the motivation to change. This motivation is more likely to occur if the patient has “buy-in”. If they see the vicious cycles in themselves, it is easier for them to buy in and get motivated.
There has never been a formal study of the fibromyalgia vortex. The following hypotheses are in urgent need of testing:
- The vortex scores (both raw and the vicious cycle score proper) can be used as a screening test to quickly diagnose fibromyalgia.
- The vortex scores (raw and the vicious cycle score proper) can be used to estimate the severity of fibromyalgia.
- A multidisciplinary treatment program that is focused on rectifying the patient’s vicious cycles can be used to help treat fibromyalgia. (This could be prioritized so that the vicious cycles that score highest out of three could be the ones that get he most intense therapeutic attention.)
Evidence and factors contributing to the development of the vortex theory of fibromyalgia
Here are several considerations that I made use of when formulating the vortex theory:
- Moldofsky found that depriving subjects of sleep could induce muscular pains in heathy controls. (See: Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Moldofsky H, Scarisbrick P. Psychosom Med. 1976 Jan-Feb;38(1):35-44 available online through: http://journals.lww.com/psychosomaticmedicine/pages/default.aspx.) Moldofsky did not use the term “pain—bad sleep—pain vicious cycle”. However, he, more than any other has studied it and made its clinical significance known known. He summarized many of his findings in a 2001 article in which he wrote: "Noxious stimuli and painful disorders interfere with sleep, but disturbances in sleep also contribute to the experience of pain…Noxious stimuli administered into muscles during slow-wave sleep (SWS) result in decreases in delta and sigma but an increase in alpha and beta EEG frequencies during sleep. Noise stimuli that disrupt SWS result in unrefreshing sleep, diffuse musculo-skeletal pain, tenderness, and fatigue in normal healthy subjects. Such symptoms alpha EEG sleep patterns that often occur in patients accompany with fibromyalgia. The alpha EEG patterns include phasic and tonic alpha EEG sleep as well as periodic K alpha EEG sleep or frequent periodic cyclical alternating pattern….Disturbances in sleep, pain behaviour and psychological distress influence return to work in workers who have suffered a soft tissue injury, e.g. low back pain….In conclusion, there is a reciprocal relationship between sleep quality and pain. The recognition of disturbed or unrefreshing sleep influences the management of painful medical disorders." (Sleep and pain. Moldofsky H1. Sleep Med Rev. 2001, Oct;5(5):385-396.)
- Choy writes that in fibromyalgia: “Mechanistically, sleep deprivation impairs descending pain-inhibition pathways that are important in controlling and coping with pain. Clinical trials of pharmacological and nonpharmacological therapies have shown that improving sleep quality can reduce pain and fatigue, further supporting the hypothesis that sleep dysfunction is a pathogenic stimulus of fibromyalgia.” (The role of sleep in pain and fibromyalgia. Choy EH1. Nat Rev Rheumatol. 2015 Apr 28.)
[Author’s comment: The author does not know how or why poor sleep induces muscular pain in fibromyalgia.]
- It is common knowledge that pain can make it difficult to sleep. The existence of pain induced sleep deprivation is well known and well established both in the minds of the general public and health care professionals. Numerous fibromyalgia patients in the author’s clinic told him attested to having more problems falling asleep when pain was bad.
- It is common knowledge that sleep deprivation leads to excessive daytime sleepiness and reduced cognitive function.
- Reduced cognitive function leads to poor performance, reduce competitiveness in the work place, and probably in some patients job loss or reduced productivity, which leads to financial problems (thus compounding the patient’s worries).
- Negative thinking tendencies lead to anxiety and worry. Worry in bed is the main driving force for insomnia.
- Worry causes agitation and disturbing chains of agitating thoughts when the person is trying to go to sleep. This contributes to insomnia and sleep loss with all the attendant cognitive performance and other problems of sleep deprivation.
- Focal interpersonal conflicts involve psychological battles that entail ideas of good and evil can include anxiety. A major battle, particularly one going for years, is not conducive to recovery and in the opinion of this author, probably contributes to central sensitization.
- Real world problems such as work, personal or financial problems can contribute to worry which makes it harder to sleep.
- There many pockets of evidence in the literature to support each of the six questions of the vortex. Here is on example: Schuh-Hofer et al. noted that amongst chronic pain patients, sleep disturbances are highly prevalent. (One night of total sleep deprivation promotes a state of generalized hyperalgesia: a surrogate pain model to study the relationship of insomnia and pain. Schuh-Hofer S1, Wodarski R, Pfau DB, Caspani O, Magerl W, Kennedy JD, Treede RD. Pain. 2013 Sep;154(9):1613-21. doi: 10.1016/j.pain.2013.04.046. Epub 2013 May 11.) They performed a small study on normal subjects using a standardized comprehensive quantitative sensory protocol after a night of sleep deprivation. Results showed that in addition to causing sleepiness, and high State Anxiety Inventory scores (P<0.01). They noted that previous studies had shown “hyperalgesia to heat (P<0.05) and blunt pressure (P<0.05)…” In the new study the subjects developed statistically significant cold hyperalgesia and mechanical pain sensitivity to pinprick. The concluded that a single night of total sleep deprivation “selectively modulated nociception…” They indicated that their findings demos stated that a single night of sleep deprivation induced generalized hyperalgesia.
Perpetuation of the patient’s fibromyalgia by the vortex
In my experience, most patients have at least some aspects of the vortex. Some have all three. In my clinical experience the interactions between vortex factors drive and perpetuate fibromyalgia. For example, poor sleep causes the patient to wake up in more pain. The pain creates worry which in turn makes it hard to get to sleep the next night.