Fibromyalgia: It's Real, It's Manageable, What You Can Do

this program is a presentation of uctv for educational and non-commercial use only so I'm Andy gross I run the Rheumatology clinic here at UCSF and like to thank dr. Chau and others for inviting me to be part of the UCSF mini-medical school pain series and I actually asked to speak about our myalgia so with that let's get going here so first of all it's always important to point out particularly with pain where there's such a lucrative pharmacology market that I have no disclosures actually I'm no one's paying me to do anything so all right so here's what I'm going to talk about so and these are questions I get a lot what is far Belgium how common is it how do you diagnose it is it real I get that question a lot where does pain come from what causes it what can I expect I'm sort of going out farther and how do I treat it so we'll get to all that stuff so let's talk about power magic here we go so I imagine a lot of the people in the room know something about this but for those of you don't what I'm basically going to kind of go through and describe what people often tell me and this particularly applies to women men most definitely get farm management as commonly as women but men definitely get it we can get come back later talk a little bit more about the men's symptoms but for women one the hallmark of fibromyalgia is widespread pain so it's just pain all over their body and they usually tell me that they wake up first thing in the morning and they have a lot of pain a lot of stiffness as the day as the morning progresses and they kind of get going they things loosen up a little bit and people usually have kind of a better time sometime midday into the early afternoon but as the day wears on people usually tell me that the pain begins to get worse and worse and people tell me that particularly if they've had a busy day then the pain really gets worse and worse so that usually by the early evening if people have been out and about and doing a lot of errands and stuff like that generally they tell me that by the early evening they kind of feel like they were run over by truck people then need to just find themselves just crashing trying to go trying to get some sleep but the second hallmark of fibromyalgia is that people rarely can get a good night's sleep and almost always wake up feeling unrest it so often they spend the night tossing and turning so even though they feel like they need a crash at five o'clock at night it's hardly than a respite from their discomfort and then finally over all that stuff people almost always tell me that they have a huge degree of fatigue that just trying to get themselves out of bed in the morning and getting up and doing anything is a major challenge so those are the three sort of hallmark things widespread pain the fatigue and the problem sleeping and I'll come back to that so in addition to that people then often tell me about a variety of other things and that's usually that's why I kind of pull out these figures like this and just kind of work from head down so so people often tell me that they have a hard time thinking it's over and over I hear about people that they have a hard time concentrating and they have a hard time remembering things and they just feel like they're in a fog all the time a second thing people often tell me about and all these things are sort of a mix-and-match no one tells me about all these things but people often tell me about some combination for some people it's really bad headaches for some people it's pretty bad jaw pain TMJ pain some people pretty bad chest pain often prompting workups for heart attacks and stuff like that where the doctors can't find much people often have bowel problems which are often described as functional bowel problems or oral bowel syndrome your constipation or loose stools or alternating back and forth with a sense of bloating a lot of discomfort particularly if people eat the wrong thing they'll notice they just there's some it gives them all sorts of problems people often tell me about urinary problems feeling like they have to pee all the time but not that much comes out almost like they have a urinary tract infection sometimes people have a lot of problems with pelvic pain prompting for women a lot of visits to see a gynecologist numbness and tingling very prominent hear that a lot and people often end up we're going to see neurologists and getting worked up for like multiple sclerosis and other problems skin rashes itchy skin that's really very irritating and people end up going to see dermatologists looking for some underlying problem and chemical sensitivity so unable to tolerate different things on the skin and that's just that's just a short list there in fact people tell me about all sorts of things in addition to that so it really is a very broad range of problems that are extremely disruptive to people's lives okay so is this a bit how big a problem is this and it's a huge problem I mean it is a huge problem so here's a so an awful lot of people have back pain but obviously that's a short-lived thing as well as neck pain osteoarthritis we see in a lot of people as they age and joints begin to wear down and that's a huge problem but generally later in life five million people it's estimated from this National arthritis data workgroup have far mileage in the country so five million so actually if you think about that that's more than rheumatoid arthritis and lupus combined as well as most of the other two as I see in fact if most of these people came to our clinic we wouldn't have time to do anything else so it is a massive problem but despite that you don't hear that much about it it's been a while since I read in the front page of The New York Times about about fire manageable also have you hear a lot about cancer so I can bring Smith to that comment you know I'm right there in the room but no one ever seems to acknowledge me and that that really is far manager okay so how do I diagnose fire Malchus so people want to know that all the time how do you diagnose this and people are always interested because there's no blood test no EMG study no procedure I can do that says you have fibromyalgia and it's often that people want that kind of confirmation people come to my clinic asking do I really have rheumatoid arthritis I have the blood test and they feel like they can't latch on that for fire mal job but actually fire Malakai diagnosed just like I diagnose any condition it's almost always in what people are telling me in addition to what I find on my physical examination so so as I said the hallmark to farm al-jihad spread pain so that's the very first thing I'm listening to for when people are coming to my clinic and talking about their pain one of the first things I want to know is well where is their pain and people with fire knowledge is going to be all over so I put this figure up here pointing out the fact that this woman has pain in her shoulder and her forearm and our upper neck and her upper back and the other shoulder and our lower back and her hip and that and that's pretty typical in fact these particular areas more central areas are pretty typical all that being said people if I'm eligible definitely can have pain in their hands and their feet or anywhere farther out but widespread pain is most definitely the norm so that's the first hallmark to it and then the second hallmark is I already mentioned is that people have a huge amount of fatigue that's very disruptive in their lives they have difficulty sleeping so they most always tell me that at least a lot of the time they're waking up feeling like they're not getting a good night of sleep they don't always tell me that they're actually can't sleep at night or they feel like they're tossing and turning all night long but almost always they tell me that when they wake up in the morning they don't feel like they got a good night's sleep and I'll come back a little bit to some of the details and then finally people often as I mentioned before complain about cognitive problems difficulties thinking difficulties concentrating difficulties remembering stuff and so when you put those kind of two groups of things together I'm usually pretty keyed in it's going to be likely the person in five mouch then I start asking about the other symptoms I mentioned before so I'm going to ask about the problems without with with headaches or chest pains and things like that and often people are going to tell me that in fact they've had workups for all those different problems by other specialties the specialist that happens all the time yes I've been to the cardiologist they said they couldn't find anything with my heart and that's helpful for me too because that reassures me that in fact does not some underlying problem that in fact this all traces back to fire management so those are the the key hallmarks to the making the diagnosis for me now there's another feature that people have probably heard about tender points there's a lot been made about tender points so where that came from is American College of Rheumatology developed this classification criteria for the diagnosis of fibromyalgia so American College of Rheumatology does this for a lot of conditions the reason why they want to do this is they want to have people enrolled in clinical studies where you can be pretty certain that the patient actually has that diagnosis since it wouldn't be very good to study the effect of some new drug in in a group of people who didn't actually have the disease you thought you're studying so they've done this for rheumatoid arthritis and they did it for lupus and they did for fire management now I don't usually use the classification criteria for making any diagnosis whether be formit arthritis or lupus or whatever but it's a useful guide and so they did this with tender points and so what they did was they identified 18 points in the body that are sensitive now these 18 points are actually sensitive in anybody fun to play with my kids so so and and so these are just all tenor of places in the body with sensitive areas in the body but in people a fireman Joe when you press on them it causes much more discomfort than one would normally expect and so people I often will see with Farm Alger I will press on these points not to actually see if they have 11 areas are particularly sensitive but it does help me to gauge whether people are more sensitive to pain than what I ordinarily expect from most people so these areas are mildly helpful and sometimes people if our mouths are extremely sensitive and truth be told some people are not particularly sensitive at all but that doesn't necessarily sway me away from the diagnosis because as I said a lot of it comes back to these two hallmarks so the tender points are not as important to me for making the diagnosis by do pay attention to it okay so that sort of is what I'm looking for in the diagnosis and then of course is one other key component all this which is making sure that someone doesn't have any other disease and that's important to do because certainly other conditions can cause chronic widespread pain fatigue and even problem sleeping so some of those different conditions include hypermobility syndrome so people who are super flexible seem to run into problems with a lot of widespread pain people with endocrine diseases sometimes diabetes more commonly serious thyroid disease can run into this kind of problem cancer most definitely can show up this way not typically but it can autoimmune disease lupus most definitely can kind of can give a lot of these different kinds of symptoms as well as neurologic disease that multiple sclerosis and Parkinson's but that being said almost all these conditions usually you can find something else going on very and then often many things happening either on blood tests or just talking to someone that really Clues at least me in that there's some underlying condition it rarely comes as a major surprise to doctors when one of these conditions is part four actually present so it actually is not a subtle art to just be able to identify someone with far Malchus a posed to someone with lupus we some with lupus is going to show up with the intense skin rashes various inflamed swollen joints things are distinctly different than people at farm alger the one other thing that people always ask me about is infections so all the time everyone's wondering well I feel terrible I wonder if I have an infection that we can cure with antibiotics and then I'll go back to feeling normal so everyone always wonders that and the big infections people always wonder about are things like HIV and EBV and then of course one of the big ones that come up all the time is Lyme disease but that being said just like the other conditions most of these things are readily distinguishable and mostly things usually things like EBV and flu usually are self-limited they go away the symptoms go away after a while EB v is epstein-barr virus so so that brings me back to the fact that usually when I'm talking to someone and I'm identifying these things and these things are usually what keys me and if someone really does have fire mal juh whereas all the other conditions usually there's a lot more computers a lot more going on than just these two major components okay so then the question is well what's causing the pain you fire around you so I'm going to come back to this figure a lot and so what I'm trying to describe here is a circuitry of pain signaling I'm going to break it down to two components so there's a component peripherally so the nerve that goes from muscles or tendons and ligaments to the spinal cord and then there's a second nerve that brings these signals up to the brain okay to the somatosensory cortex if you want to be exact so two major sort of connections so the peripheral nerve and the central nerve coming on up so so that's how pain signals are generated so then of course people so researchers began to ask well where is the pain coming from and so they took a very methodical stepwise approach and one of the first things that people started looking at is you serve some problem out here is there some problem in the muscles or the tendons or ligaments somewhere out here that's causing all this pain so so in thinking about we're painting them from so certainly one place for pain to come from is joints so you're the hip joint there or the spine and then also of course they're the bones themselves and then right next to the bones are often these structures bursa or verses that are basically protecting the bone and providing lubrication and a lot of different studies have looked at the joints and people with fibromyalgia and no one's been able to find any abnormalities with the joints now sometimes people if I'm ouch can also have osteoarthritis but that's not to say the osteoarthritis is causing the fire mode all right so then people look at other structures and things including muscles and the tendons that connect the muscles to the bones as well as nerves and wondering well is there some problem there is there tendinitis information attendance or is there nerve damage like what diabetes does but in all these cases no one's been able to find any reproducible evidence that people with fibromyalgia have any damage to any of these structures so it doesn't seem to be a problem in the structures themselves well so that then brought people to wonder well if there's no damage maybe if we think about the muscles where a lot of the pain is maybe there's some metabolic problem maybe the people of fibromyalgia just something's something's different about the muscles where there's a metabolic problem that leads the muscles not working quite right quite right and that's going to lead to pain so a lot of studies have been done looking at muscle metabolism doing biopsies measuring production of metabolites and what-have-you and no one's been able to reproduce ibly find any problems there there's definitely been studies here or there that says yes there's some problem but when people have gone back and done things carefully over and over you haven't been able to show any any problem that that scans up over time so that doesn't seem to be the problem okay so if the problem is not out here so then people started wondering well maybe the problem is somewhere in this part somewhere in the nerve connection and so people started wondering well maybe there's something happening at the in the nervous system that's leaving people more sensitive to pain and the hints of that came in looking at the cerebral spinal fluid so the the fluid that you do from from a spinal tap where it was noted in various studies that there seem to be differences in the levels of neurotransmitters that seem to be associated with pain so it seems to be subtle differences there and that doesn't really explain where the pain is coming from but that gave a sense that there's something going on the level of the central nervous system there that seems to be leading people to have more sensitivity to pain alright so furthering that people started looking at how people with fibromyalgia experience pain so researchers started looking at how they experience me and so what they found is that in fact people if arm alg are more sensitive to all kinds of different paints whether it be a heat or a cold or the pressure and so that's illustrated in this figure here try to avoid showing you all too many data slides it's a little bit dry but what this what this slide is is just having a researcher press with a very fixed amount of pressure someone in the same spot in their body and they do this for a live different people and they see when they pressure it when they put two pounds per square inch whether it causes pain so they just ask the person does it is that painful and they found with this group of people with fibromyalgia that it was roughly one-and-a-half pounds per square inch or forget what the exact units were that was causing pain whereas normal people about people without you know chronic pain issues we were able to we actually had much higher levels of pressure that would actually then elicit pain and then they did one other important control is to look at people with chronic pain but in sort of a very focal area so people with chronic low back pain and these people in fact actually look more like the people without pain so there really does seem to be something different in people with fire knowledge about how they're sensing pain now the problem with this study is it still is very subjective you're asking people what do you feel and that's not as exact as you'd like to be so to try to take people out the subject the subjectivity of people out of this experiment the number of researchers have done this in a different way and there's gonna be a little bit complicated but what the researchers made use of is this kind of reflex so I think everyone has it has had the experience of touching something that caused acute pain and before you know it you've withdrawn your hand or your foot so that's a normal pain reflex it that actually happens faster then the signals can actually get up to your brain so your brain is not involved in that at all so that you made use of this reflex so what they're going to do is they're going to apply a stimulation out here and then let it loop through the the spinal cord neurons there the dorsal Horn and then come back to the muscle and you're going to measure twitching and the way they're going to do that is something called an EMG so neural eye is a nerve or nerville neurological study that's done where you apply electrical stimulus and then actually with a needle stuck in the muscle you can feel the needle twitch so if you apply enough enough stimulus here the the spinal cord will register pain and then the muscle twitches and you can measure that okay and so what they did was they they added increasing amounts of pain until finally the muscle twitch increasing amounts of current electrical current until the muscle finally twitches and they did this with a lot of people and the difference is not huge but it is significant so what they're showing here is that people with fire male Joe had twitches at lower levels of current than people without fire male juh and to me that's very important because what it really shows is that people of farm al jarreau logical level without even asking about it actually the way the spinal cord is sensing pain is more sensitive than people without fire manager so the point there is that you really have the the issue really seems to be here at the level of the spinal cord and those fibers are sensing pain that make sense okay and so what this has been since termed is a central so central nervous system central sensitization to pain or another way I say is a pain sensitization process okay so that seems to be the phenomenon in farm algin and not only does this apply to pain from from the musculoskeletal areas or what people perceived is from the musculoskeletal areas but in fact because this is happening at the level of the spinal cord and the central nervous system in fact people are more sensitive to pain signals that they perceive coming from anywhere whether it be from the gut from showing up with irritable bowel syndrome or from the bladder there are sometimes diagnosis interstitial cystitis or from the head headaches or from the jaw TMJ disorder so all these things are phenomena can be phenomenon particularly people fire Malaga of increased sensitization to pain and in fact there's lots of people without fire Malaga so without the widespread pain part but they do have problems with fatigue and poor sleep and they often have pain problems with pain coming from elsewhere so this in fact this phenomena of a central sensitization the pain seems to apply not just to fire Malaga but people with all sorts of different conditions where it's hard to find some underlying disorder so not only do five million people with fight hit in the United States have fire Malaga but in fact a huge number of people have problems with these other different kinds of conditions and that really may sort of signify that the same sort of process is going on there it's actually applying to a lot more people so in fact they often in the room is actually a hell is a heck of a lot bigger than just the 5 million people with fire mallinger ok so what's causing this you know what's that why why do people get this how do they end up with this problem and we don't really have a very good or satisfying answer to that but we have some clues so from a variety of genetic studies done in over the last 10 years or so it's become increasingly clear that there is a genetic predisposition or a genetic vulnerability so you actually can find variations and genes or single nucleotide polymorphisms that actually predispose people to pain and the actually some of these mutations really run in families not always but it can run in families so there really does seem to be a genetic predisposition so then the second thing is that it's not uncommon for people to tell me about the development of farm algae after they've had some sort of traumatic experience it's not always the case at all and it's not and sometimes this happens after they develop our mal juh but then things get a whole lot worse but it's very quite common people tell me about some sort of traumatic experience so some of the things I've heard I've heard about are things like a pretty bad motor vehicle accident in fact there's been data suggests that in fact people after a serious motor vehicle accident are more in fact more likely to develop our mojo other things serious infections and other medical conditions that prompt admission to hospitals and particularly intensive care units very calm and see that and another just regular sorts of infections where people just feel lousy so I mentioned earlier Lyme disease so truth is that people often after they develop Lyme disease we don't see it much out here but certainly on the East Coast people feel horrible in they have Lyme disease they feel horrible and then the symptoms linger and linger and linger for most people they recover from those symptoms but it can take a while but for some people they seem to go on and develop fire Malaga now we know that the bacteria is long gone we know that but people continue to have symptoms and so again that sort of pointing to the fact that some sort of physically traumatic event seems to predispose to the development of our Belgium ok so then but it's not just a physical trauma it's actually emotional trauma too that can do be just as effective seemingly at precipitating fire mallinger and this really runs the gamut and I have a sense that often people are not telling me about this but I also have a census it's incredibly common one of the things that people often tell me about are the loss of a loved one all the time I hear about people either developing fire Malaga or having much worse symptoms after they've lost a parent or even more traumatic is losing a child but in addition to those kinds losses it's not uncommon well one say it's not uncommon but occasionally I hear about people with a more distant history of something much more traumatic particularly sexually traumatic people are often reluctant I think to tell doctors about that so I don't think I don't care about it that often but I have a sense that it's actually a huge problem out there and somehow that prior trauma whether it be violence or sexual trauma can lead to the development of fibromyalgia so those seem to be the some of the things that trigger this but as I said that really is not a complete list and it doesn't give us a clear guide to why people actually develop fire male juh but it gives us some hints ok so is it important that fibromyalgia is diagnosed well the answer is obviously yes to that so I think you know from a more altruistic or societal sense it's important because if fire mal'chik goes undiagnosed people actually end up at racking up a lot of doctors visits in a lot of tests so here's a study done by a group where they actually estimated out the the the expenditure of resources on people who were diagnosed with fibromyalgia versus people who are not and what they did from their modeling is what they or they learned from their modeling is that people who don't aren't diagnosed with fibromyalgia expenses and numbers of tests go up and up and up and doctor's visits and everything else related to medical care versus people who are diagnosed with fibromyalgia things tend to level off so that emphasizes that by getting the diagnosis of fibromyalgia people with spent end up spending less time going to the cardiologist for that chest pain and going to the urologist for that for that discomfort when they urinate and going to the neurologist because of the number one um this and tingling now obviously if you have fired manager well I mean so what I don't really care about about what the impact is society mostly I just want to feel better and I want to find out what's going on with these things but I think it's important to also remember that um that if you're doctors odds are you're going to get a test and if you're going to go to enough doctors you might end up with some test that's going to be abnormal that's going to prompt even more tests and you might even end up with unnecessary procedures from time to time I think people actually have things like gall bladders taken out because of chronic abdominal pain where it doesn't solve any problems at all in fact after they've had the surgery they may even feel worse so I really emphasize to people that it's important to be cautious about pursuing lots of tests because it actually can lead to a lot of unnecessary things so I think it really is important that people are diagnosed with fibromyalgia okay well what you know people were then when I asked well what's going to happen to me well will I feel better someday so I put up this slide this is a slide from from Fred wolf scroop out in Kansas and I put it up is it's it's optimistic that people symptoms seem to go down in time in this case over a scale of 12 years now the slides a little bit unfair now this is a scale from 0 to 31 and I'm showing you that the average score decreased from 23 to 17 but really the scale should start at 0 so what this is pointing out is that most people 12 years later still have a lot of symptoms you know maybe you know improvement of 25 percent over that period of time another study was a little bit more optimistic in that saying people got that a reasonable percentage of people actually five years later we're no longer diagnosed or firemen job but I think the the jury's still out on that one in general my experience is is that people's symptoms seem to wax and wane people seem to have good months and bad months people seem to even have good years and bad years but it's unclear to me if this will ever go away now that being said even though it's never going to ergo to what go away I think there's definitely things that people can do that will help control their symptoms and have them be more functional and do more things that they want to be doing so that gets me a treatment and the thing I really want to emphasize and this part of the talk talking about treatment is that there's going to be no one treatment that works great so people try medicine and people try effects that affect the mind and people try interventions that affect the body and no one intervention is shown to be truly very effective but that being said when studies have looked at a multidisciplinary approach then you start seeing more of a difference being made in people's symptoms so it's very important that the people take away from this talk that there's not going to be any one thing that they should be doing it's actually a much more comprehensive approach okay so why don't we start with medicine since that's the easiest thing to talk about so let's go back to our model here so there's a couple different places that we can intervene with medicine as we think about this system so one place we can intervene is is break back here at the dorsal horn and that's with affecting North and Efrain levels so norepinephrine is learn the neurotransmitters that's considered one of the fight-or-flight neurotransmitters the neurotransmitters that allow you to run away or or or fight back against the line that's about to eat you and obviously in fight or flight is important not to be so much concerned about pain when you're trying to survive so the approach has been taken to try to increase norepinephrine levels which will then decrease pain levels and there's a number of different medications that do that so one class of medications is called the tricyclics into your essence now people whenever I start people on something like elavil people say well why I'm not depressed I'll need an ether present and what I want to emphasize here is that most of these medications are antidepressants but they're being prescribed usually at doses lower than what you prescribed for depression with the goal here being that you're trying to increase norepinephrine levels to damp down pain and also one other side of one other beneficial effect of all these medications is they often allow people to sleep a little bit more deeply it'll come back to the importance of that so tricyclic antidepressants as well as this group of drugs called dual reuptake inhibitors and dual reuptake meaning serotonin and norepinephrine so you're trying to increase norepinephrine levels now as always with medication there's always side effects and these norepinephrine tends to dry things out so people divide complain about dry eyes and dry mouth to me a lot when they're on these medicines but they're they're reasonably effective in a limited number of people and it's a little bit unclear to me how long that effect lasts for so the studies say that probably about half of people respond to these drugs maybe a little bit more and the studies say that people probably have a 25% improvement in their pain so it's not a huge improvement but it's a solid improvement and when you're in that much pain you'll take 25% so they definitely play a role it's also as I said just said a little bit unclear to me how long they work for it's not uncommon for me to ask someone a year later do you think the cymbalta is working and people will say I don't really know so I think these medications are helpful in getting pain under control initially but it's not necessarily something that's going to work for a long time not necessarily I think we still need to learn more about that obviously the drug companies aren't going to be you know rushing to do these long term studies most of the studies are usually for a half a year tops okay so the the next group of drugs I want to talk about are ones that are in effect this level so these are the neuro the the nerves that are releasing manners that then stimulate the dorsal horner and what these drugs are going to do is block the release of neurotransmitter here by these nerves so to help block that neurotransmitter release so you don't have signals coming in from the periphery so these drugs the the one that you see in TV all the time is lyrica gabapentin is the older one lyrica in fact is gabapentin but it's just a different form of it but in both cases they can be helpful people usually tell me they're more helpful for more burning type paints so when people have tingling burning type pain coming from anywhere in their body these medications tend to be more helpful but on the flip side people often tell me that these medications often make them really sleepy or really foggy and most of the time I find people don't like them so I'm not particularly fond of these medications except in people who really complain about a lot of that burning type pain okay so to review some of the data we have out there about drugs so we just try talked about the tricyclics antidepressants one of which is amitriptyline although the other group is the dual reuptake inhibitors and so these are going to increase norepinephrine levels and and decrease pain help people sleep a little better the second group are gabapentin pregabalin and then a third or a third through drug if you will that that helps the tree farm algae's flexural or cyclobenzaprine that's a muscle relaxant and it actually does seem to be helpful in some people although truth be told I think a lot of it's because it actually has some effects of elavil so it actually is mimicking these actions I think it's doing less to actually relax muscles and more more centrally and then one other drug that that's out there that's shown to be somewhat effective is drug called tramadol this is a kind of like codeine light it's a it's a it's a opiate partial agonist so it doesn't quite work like something like vicodin or oxycontin but it does have effects that seem to be at least somewhat helpful in people farm allergen that being said it can cause a fair amount of constipation so that doesn't always go so well other stuff so the various end sets so drugs I think we're mostly familiar with are advil motrin Aleve over-the-counter those have been studied at length as well as other ones and no one's been able to show that those are effective or over a sustained period of time for people with fibromyalgia that being said I sometimes recommend that for people who have pains in other areas of the body or they have a specific pain that they're trying to treat so for example someone who has far mal jehoahaz a lot of arthritis in their neck they might benefit from the NSAIDs because having less pain coming from the from the neck arthritis might actually help to improve their overall pain so sometimes there's a role for things like motrin advil one on treating things like that prednisone has been looked at at length now it's not uncommon for people to come in to see me who say whoa I was sure I was diagnosed with lupus and I really think I have that because when my doctor treated me with prednisone I felt much better but the truth is that you can give anyone a high dose of prednisone for anything in fact the steroid effects are very are very potent on the brain and can have people feel better but that effect tends to be short-lived and then of course you're running to all the other side effects of prednisone and those kinds of doses of 20 milligrams a day or more they're extensive and can be severe and can ultimately lead people to have many more problems than they start out with so I definitely steer people away from prednisone benzodiazepines so things to help people sleep not a big fan of I'm often it can be helpful initially people can say I I sleep so much better when I have my ambien which is a semi benzodiazepine but in general my experience is is that in time people find that they can't get a good night they can't sleep at all without taking their ativan or their ambien in fact they end up right back in the same boat of not sleeping well and relying on these drugs to sleep at all so they become taller eyes to them so I don't recommend been surveys beats there are other medicines to help sleep like trazadone and some other ones and uh and there's variable experience about how effective they are and then finally opioids so I definitely know some rheumatologists for prescribe opioids for fibromyalgia I'm not a fan of it they haven't been shown to be effective or a sustained time at the same dose similar to my experience with benzo days means I think what happens some people start on opioids so things like vicodin or oxycontin it's like they do have pain relief most definitely they do have pain relief but the problem is that that pain relief the effect tends to wane over time and then people need a higher dose to get that same analgesic effect and people tend to then escalate higher and higher doses and then that tends to eventually have a lot of other effects on their body including them making having people feel very groggy and doped up so I'm not a big fan of treating people with narcotics some rheumatologists say that well that's the only thing that's going to make a difference for some people their pain is just so bad and I understand that point of view but I think in the long term that's good ultimately going to work against people so if they do need a narcotics I always recommend that it be for a limited amount of time and that people work very hard to try to taper themselves off of it okay so that's the drugs so in my next cut is my next comic is ask your doctor if taking a pill to solve all your problems is right for you and you know I think we all feel like that sometimes like we really you know we have some problem and we just wanted to be gone and want to be easy just you know take a pill and chase down the glass of water you feel bad but of course unfortunately is not often like that and in fact when I ask most people if they choose to want to take pills or not most people are say no I don't really want to take pills in fact if given a choice between having to take pills or other strategies people are usually going to want to turn to the other strategies now that's not always the case when they're really really really bad pain but when thinking about it in a more global sense that's the usual choice people want so that brings me to my next topic which is the body and what are things that with people five myalgia can do for their body ok so that brings me to exercise which has been shown over and over in multiple studies to have people feel better sleep better and function better and this has been shown in many different studies with many different interventions so the different things I tend to talk with people about our walking using an elliptical bike or an exercise bike swimming great swimming is outstanding whether it be swimming itself or water aerobics stretching and tai chi or key Qigong so a little bit about each of these so walking has been shown over and over to be the the intervention that people are most likely to incorporate into their lives and keep up with so I'm a fan of walking now when I say walking I'm not talking about you know what people is asked well what about you know walking around my house doesn't that count now that doesn't count so this is exercise so what that means is that you're identifying a period of time when you're going to go out and do something good for your body if possible that means that you're going to go out and exercise at a pace where your heart rate is going to go up a little bit ideally you might even get a little bit sweaty now for some people when they're just raw that might mean literally five or 10 minutes literally that's how much they can do and then they're just wiped but what you're going for here is somewhere between 30 and 60 minutes somewhere in there and it might take might take honestly three to six months to get to that level people have to build up very slowly but that's what you're aiming for and walking can be very hard for some people particularly if you have low back problems or a lot of pain and the sides of the hips or a lot of arthritis in the knees all those different things can make walking much more challenging so then it's important to turn to something else so bicycling sometimes can be very good for some people I find these elliptical trainers are a little bit better because you don't have to kink your neck back which can bother some people's neck a lot and seems to be very gentle on the rest of the body as I mentioned water aerobics and swimming are fantastic because of the zero gravity nature of water and I'm a big fan of those things now of course a problem though is that except for my with with minor exceptions it's rare that people can actually do water aerobics or swimming every day but if you can incorporate into doing at least a few days a week that's fantastic or even a couple times a week and the Arthritis Foundation has a lot of different programs for for the around town for this kind of thing stretching so as I mentioned people with fibromyalgia have a lot of problems with stiffness people for really really stiff and having a stretching program to do every morning I find to be really important and it's really something that I think is important to do every morning and ideally even twice a day and I ask people to work with a physical therapist to develop a whole stretching program for them in working with it there are physical therapists to some for important to find a physical therapist who's familiar with fire male Djem people with fire Maui will find a sports therapist tend to come back to me saying oh my god he put me on these positions I've never feel in my life so it's it's important that you find someone who's familiar fibromyalgia and familiar with building a very gentle program that people can add to or intensify over time to make it more effective but not it is not immediately going to make them feel much worse in addition to just generalized stretching it's not uncommon for me to see people with farm alger with extremely tight muscle groups and specific areas often tied into some sort of problems with osteoarthritis or something like that so I often are referring people the physical therapist not just to develop a generalized stretching program but often to focus also on specific problematic areas so all the time I'll see someone with a extremely tightened muscles in their neck from holding themselves kind of like that all the time or people who have very tight low back muscles and buttock muscles and a lot of pain going down the sides of the legs and they have extremely tight muscles there and so then the physical therapist will build a whole program for that so I find that to be very helpful in addition to this sort of aerobic exercise and then finally Tai Chi or Qi Gong there is recently a really nice study from Tufts my alma mater looking at the impact of Tai Chi on people fire myalgia it was published in the very prestigious New England Journal of Medicine because it was so effective so I'm a big fan for those of you unfamiliar with Tai Chi it's a it's a basically in a sense of martial art where people are doing different kinds of poses that have a combination of isometric I'll element to it as well as a some degree of stretching and incorporate into all that there's also a meditative component and that and that grouping of components seems to be very effective for the management Firebaugh job and so I definitely recommend that people give that a try ok so the last point I want to make is that when you have diffuse pain it's really hard to do these things it's really really hard to do these things and all the time people come back and tell me that in fact when they did do all these things all right I did it I did sided I'm going to go and I'm going to walk 15 minutes a day and they say and they come back and they say I did that for three days and that was it I couldn't move for a week and so what I want to emphasize is is that it's important for people to start very gradually and in a very regulated sort of way and I in fact encourage people to pull out a calendar and actually say what they're going to do each day starting with something ridiculously easy and very very gradually building up and knowing that when you start on the 15th here that um that didn't even realize I was ten I didn't even focus this tax day wait maybe you want to start a fifty it start before that um that you're that you're to recognize that you know come the the 18th you're going to be feeling worse probably when you first get going but nevertheless what you wrote is that no I'm gonna stick to it I'm going to do it says in the calendar I'm gonna do ten minutes I'm going to keep on going with this and stick with whether your plan is really important stick with your plan so pull out the calendar and Mark what you're gonna do so here lie tips and I have this in your handout and it's completely unreadable in your handout so if you want these tips you should send me an email just email me to andrew gross at UCSF edu so now everyone on the Internet is going to have that too but actually you can get that off the UCSF website too anyway and say hey can I have the slides in in a more legible format and I'll send them to you in a bigger format but these are reason that these are helpful tips that I found to help you get going and keep going going alright so talked about exercise diet eating healthy what about that well everyone always ask me what should I eat which I and the truth is that there's no convincing data that there's any one diet or any one food or any one nutrient that actually can reduce pain so we don't have any data look at that and people have looked at this in a variety different things of vegan diets and living foods diets and whatnot and there's nothing convincing but that being said we do know that people who have higher body mass index people who are obese are more likely to have farm algin and we know that people who are beasts with Firebaugh juh often have a reduction in symptoms when they lose significant amounts of weight in fact there's even a one study looking at bariatric surgery where people lost huge amounts of weight where actually they had major improvement in their symptoms so what that points to me is that while there might not be any one food that's going to actually reduce people's pain I think eating healthy in addition to exercise is extremely important for basically taking care of your body avoiding weight gain and actually facilitating some weight loss so so people as I said always ask me what should I eat and I say well it's actually up to you but I think whatever you do you should try to find some sort of healthy diet that actually is going to work well for you and there's a zillion different kinds of diet books out there to make be different suggestions but a really good resource for that is um is actually the US government so the USDA Department of Agriculture came out with this Dietary Guidelines for Americans in 2010 this is different from the old-fashioned pyramid because it really emphasizes a whole combination of foods but in limited limited amounts so they emphasize that you want to kind of limit your total caloric intake one of the very important things and hard to do in American society where you get you know a huge platter like that to remember no no don't eat the whole thing so that in combination with physical activity now for those of you who won't really want so what else can I do for diet one thing I do point you to is the sponsor of this talk is a Osher Center for Integrative Medicine here at UCSF and they have a live different people in their group we like to think a lot about diets and work with people about about modifying their diet to something that works well for you okay so that's diet so then the third part is getting good night's sleep and obviously as I want at least one of the things I've mentioned the get-go is one of the hallmarks of fire mouches people feel like when they wake up I just don't feel like they got a good night's sleep one of the interesting studies that came out of Stanford in 1970s was a study by this guy while toski who looked at he took a bunch of undergrads and graduate students and he hooked him up to a EEG s and measured their sleep waves and each night when they would drop into the stage for sleep so that's a deep deep deep relaxing sleep not the rapid eye movement part but the deepest most relaxing sleep and he measured me that's where they people go into Delta wave sleep and whenever they would drop into Delta wave sleep he would play loud noises to pull them out of that stage for sleep usually not enough to wake them up so that if you ask people did you wake up last night they said well I don't know maybe once or twice I heard something but no I don't think so I think I slept okay but after doing that for about three days people reported that they felt like pretty much like they had fire mal'chik they had paint all over their body say it headache said domino discomfort they're a mess after only three days the one other cool thing about that study is they happen to have in that group three people who were athletes three people who were long-distance runners and those three they couldn't wake them up they couldn't get him out of stage four sleep they just went right through whatever we play and and yeah I think that's cool and it reminds me that exercise is important not just for taking care of your body but actually is helpful to taking care of your mind and getting a good night's sleep so so sleep deprivation is associated with the development of widespread pain people with fire mal'chik commonly have disturbances in their sleep and it's important to try to return to restorative sleep and so that brings me to my next tips page which you can again email me for or there's this is all over the way and these are just sleep hygiene pointers and one of the one of the most important things is just having a regular bedtime and even more importantly having a regular wake up time so you should be waking up the same time every day now obviously there's limits to what people can do and we all busy schedules only off to do different things our lives that doesn't always allow that for me it's my three-year-old who decides to come in at different times but as much as possible trying to wake at the same time and getting a full night's sleep is incredibly important okay so that's Pharma so that's a that's just the the sleep part and then finally I have to put in I'm a doctor I have to plug don't smoke and in fact there's good data that smoking makes paint worse now now the the minor caveat there is that when you stop smoking you tend to gain weight and then people tend to have more pain but that again is that's that's a manageable thing in the long term it's going to be a it's going to be a good thing to stop smoking so I highly encourage people don't smoke okay so some tips make smart choices don't smoke eat well keep an even keel really important so again with that calendar that people are saying alright this is what I'm going to do this week and I'm going to stick with it and I'm not going to rock the boat and try go to a super gung-ho and I'm not going to pull back I'm going to do things are a very regular way and maintain a healthy lifestyle okay so the last part is the mind this often gets discounted in part because people are often seeing medical doctors who are less trained in this area and in part because of the stigma of fire Browns of being all in people's heads it's all in my mind that's just made up I don't really I mean you don't really have pain it's just all in your head and so the last thing people want to do is talk to a therapist about something going on there might but in fact it's been shown that this is incredibly important so one of the things that's been worked out in time it's actually there's a vicious cycle or a pain cycle that's present in people with any kind of chronic pain and the the phenomena is is that in people with with chronic pain it leads to a lot of negative thinking so anxiety of course over the pain you know because you're tired of being and tired of having were stayin problem sleeping and then P and not coping well with the pain and these all seem to lead into even more pain so it becomes a sort of entwined mess in fact there's pretty good data behind this so a neuroscience level and this is pretty cool so there's actually a whole system in place here that actually modulates pain so not only is this nerve coming in but there's actually a choice here where some signals can actually instead of adding to pain can actually reduce it dr. Henry was talking about this last week about when you whack yourself then there's a tendency to then rub the site that you whacked and that rubbing is actually stimulating different fibers that are actually going to inhibit pain signals so that's the idea to that that there's actually coming from the periphery there's ways to stimulate nerves that actually give inhibitory signals to modulate pain so there's a lot of complexity there but even adding to that level of complexity there's actually descending fibers so fibers coming down from the brain that can modulate this and they can they can they can increase it and so to block pain or they can take it away to actually make pain worse and one of the things that's been appreciate it is that negative thinking if you will so depression or anxiety or catastrophizing really oh my god is veins the worse in the world that actually can is shown to lead to pain getting worse and this very solid neuroscience behind that so this is clearly a problem it actually makes pain worse so I like this slide and I like this quote what would life be like if you could influence the way you think and feel what would life be like if you had that much control that you just that you could you could influence the way you feel and that brings me to this sort of peaceful looking slide and things that you actually can do to do that without taking drugs so that brings me to cognitive behavioral therapy so cognitive behavioral therapy has been shown in many different studies to be very effective and the the tenants of it are this that there's education component to it understanding the pain or where pain is coming from goal setting so recognizing that well you're probably not going to go out and run a marathon but there are certain things that you should be able to expect to be able to do relaxation and then as I was just alluding to identification of dysfunctional thought dysfunctional thought patterns and techniques to counteract negative automatic thoughts so basically ways to challenge you know when you're in the mode of this is horrible I've never felt this bad in my life ways to challenge that thinking now obviously that's not a normal thing for people to do you know when you're in survival mode of just trying to get through the pain you're not going to be thinking all right how can I challenge these negative thoughts and that's really where cognitive behavioral therapy comes in because honestly you need coaching in that you need someone to kind of teach you how to be able to do that and do that in an effective way where it's actually going to be able control of pain so as I said there's lots of different studies looking at that lots of and fire Malaga showing that people function does improve after a six or eight week course of cognitive behavioral therapy and in fact even more cool there's neuroscience to even back it up so going back to this sort of thing remember the experiment where we're actually putting a stimulus and then measuring the sensitivity in the muscle twit without through the muscle twitch so we're measuring how sensitive people are to pain what was actually shown is that after six weeks of cognitive behavioral therapy people's sensitivity to the stimulus went down which is pretty cool so after six weeks of just talking to someone people's pain levels actually became there people were less sensitive to pain and not only was there a less sensitive after the six weeks but six weeks after that not having anything afterward people continue to have that effect so again I thought that was pretty cool that's simply by talking to someone you can decrease your sensitivity to pain well talking to someone in learning techniques so so that so they're young so learning how to to challenge negative thinking helps to improve this this inhibitory response to decrease pain levels okay so the very last thing I want to talk about is um is working with people in your lives and your relationships so it's clear that farm algae is extremely hard on couples I see that all the time it is extremely hard in couples as not just couples but of course it's people's entire social structure where people feel like they have all this pain but no one else can actually see it and so they end up just feeling very isolated and this was studied nicely by this group looking at relationships and whether they're positive whether they're beneficial or detrimental and what they found is that it kind of not surprising it divides into two groups so when there's when people's relationships create a level of understanding and supportiveness and acknowledging their pain that tends to be very helpful whereas in relationships where people's pain is discounted and it can be discounted in one or two ways it can either be from denying that's obvious right well I don't see your vein so you know buck up but equally problematic is this sort of thing of being patronizing well let me take care of you you don't have to do that and you know you all you're doing too much that's also problematic so what I really encourage people when I when I see them is that it's important for them not not just them to learn about farm alger in fact people in their lives to learn about Farm Alger Hiss effects and what they can do together and that I really it hasn't been as well studied but my sense is over and over that that's incredibly important so that people feel that the people in their lives are helping them to manage and to be more proactive in their management and help them feel better okay so summarise it so I summarized the medications and with summarized other stuff so moderate evidence for efficacy cognitive behavioral therapy aerobic exercise education group therapy a lot has been looked at for strength training and acupuncture and there's limited evidence I think that the main thing we've learned about acupuncture is it's less about where the acupuncturist puts the needles that actually seems to be less important regardless of where the paint whatever the source of pain is whether five manager or osteoarthritis and what's more important is that you have a very good acupuncturist whose very presence is reassuring and supportive so going in and seeing acupuncturist you're not helping you're not comfortable with probably not great strategy biofeedback seems to have some role and that plays back into cognitive behavioral therapy the the Osher Center does a lot in this direction with something called mindfulness very weak evidence working with chiropractors massage therapy electrotherapy ultrasound and then one thing that that was more popular ten years or twenty years ago where these trigger point injections injecting steroids into areas that were particularly sore and in fact there's excellent evidence that if those if that does work it doesn't matter what you inject so the old studies went back and it looked at you know injection of steroids and and it was usually start red plus lidocaine and so then they just are you know novocaine numbing medicine and they found that there was no difference whether you just did the novocaine alone or novocaine plus historic so then people well alright well what about the novocaine in the steroid versus just you know salt water and that worked just fine and then they said well alright what about if we inject nothing at all we just put the needle and kind of torch it around and that actually just works work just as well as everything else so um so you know over that which gets us right back to kind of that direction so um so I'm not a big fan of that stuff all right so um so in summary fire major represents a condition of central sensitization to paint people are more sensitive to pain and that's very real that there's drew neuroscience behind that so systemic disease should be excluded but I put that up there too emphasis is that usually is fairly readily apparent to doctors when there's a disease apparent when there is a disease present that's actually masquerading as far mal Djem it's not usually a secret fire mal Jay is important to diagnose and limit unnecessary medical utilization and limit the the subjecting people from unnecessary things and procedures and the most definitely fire mileage is manageable but it takes a very conservative effort with multiple different approaches and it's rare that you actually someone's going to be able to get away with just taking a pill each day and feel radically better that'd be great that's rarely the case so it's real it's manageable now you know so with that I just want to say it everyone can feel like The Incredibles and I want to point out some some help from my friends so Bev leah is here at the at the at the Langley Porter Institute she's a therapist and really specializes in a lot that we've learned about cognitive behavioral therapy David Clayman is uh it heads up the sleep center here at UCSF and my wife always is as a physician really it provides me very helpful feedback so with that and then additional stuff you can't read in your handout but this is a journal article and as I said if you email me I can give you all the stuff but this provides a lot of resources for people with fibromyalgia both books and videotapes and websites and what have one final plug I want to make is for the Arthritis Foundation they're here in Northern California San Francisco and they run a lot of different programs for people with fibromyalgia they're extremely helpful and I highly recommend that people check them out too the Northern California Chapter of the Arthritis Foundation so thank you all right so okay so I imagine we'll have a questioner - okay yes ma'am yes it is seeing children it's unusual in prepubescent children so but starting around 16 or so definitely you see that frequently in particularly young girls what do you mean no it's not it's definitely not in our immune disease so that kind of gets back to those questions you have that the the earlier slides about looking at joints and muscles and tendons and there doesn't seem to be any inflammation there no damage no information so it most definitely is not an autoimmune disease what in terms of and I think what I want to emphasize there is that there doesn't seem to be any any any structures that are that are breaking down the body including nerves that everything is actually intact but the problem is is the way the central nervous system is picking up pain signals that's fundamentally the problem so the central nervous system is actually reading things in a way where it's more sensitive it's almost as if you change the thermostat some so that seems to be the problem and there seems to be these factors that lead to it but exactly how we don't know sort of brain scans you can see of emotional pain and physical pain showing up at the same location yeah is that related to a job so they're there studies out there looking at things like PET scans and MRIs and and how how the brain responds to different kinds of trauma and I think studies have looked at people with physical trauma and people have looked at emotional trauma and so then there's a lot of effort trying to correlate what they learn in these studies from physical or emotional trauma to what is seen in people with different kinds of conditions including fire mal jaw or chronic fatigue and things like that and trying to extrapolate well what can we learn from that and the and my response is is that unfortunately I don't know enough about that research to give you all a decent answer on that one that would yeah it would be a better topic for some of the neuroscientists yeah yeah so what do I make yeah what do I make it the fact that that um that emotional trauma or physical trauma can set it off you know mean it's a tough question the answer I know that you know in a sense people being in pain whether it's physical pain or emotional pain has very real effects on people and I think we've we've all seen friends and family go through those kinds of things so perhaps in a sense it's not that different yeah yeah so the question is is there a relationship between mental illness and fibromyalgia so actually no for the most part so some caveats so things like schizophrenia do not for your suppose to fire Melcher depression actually does not predisposed to fire male job now a lot of people with fibromyalgia have depression but that seems to be more normal response to be in pain all the time the one thing that seems to predispose to farm algae is anxiety disorders so people with anxiety disorders seem to be more likely result chronic pain and chronic fatigue yes sir yeah so what kind of pain am i talking about what kind of pain to people if I mount you have and and the answer is I bet if there's people in the room we could probably get a different answer for everyone with fibromyalgia it's completely different and it's even more different for guys than from women from guys it tends to be much more focal and much more intense but it's every it can be anything so for some people it's a burning pain for some people it's a throbbing pain for some people it's just a suppressing pain it really is incredibly variable so the noise way beyond the noise yeah its way so you know I think one of the things to emphasize about farm algin is that it's going to have some sort of functional impact so people I think most people a farm manager will tell me that in one way or another it's affecting the way they function that they're less likely to do you know be as active and do these things with their friends now they're like with all medical conditions there's a spectrum some people with really really bad some people not so better and and you're not necessarily more likely to get worse and worse symptoms unless certain things happen so for example you know you're pretty achy but not too bad but then all of a sudden your mom dies and then it's not uncommon for people to show up saying I am so much worse or the person who throws her back out and spends a month in their bed and stops exercising and doing other things that they know we're good for the body and they're doing a whole lot worse I hear that all the time so so there are certain things that can tip it off and make things a whole lot worse but in terms of the quality of the pain anything goes yeah so the question is going back to some of those last slides about about in the having positive relationships being supportive or negative relationships we're denying or patronizing and how do you get people to be more supportive and less patronizing or denying you know and I don't have any great answer for that because of course that's the challenge to enrolling people and some idea but nevertheless that is the idea of pointing out and it may if it works you can say doctor Gross said that um that it is more helpful to me and I if if you're more supportive and one of the things that then is helpful is if you find something that you've read or seen that helps people to better understand what you're going through pass that on to them how give them a better sense or just how or if or if they're up for it and sometimes they are and sometimes there are just talk with them about what it's like and how you've been limited and how it's affected your life so that's definitely a challenging thing but um it's a really challenging thing but it does seem to be important yeah so I mentioned the Arthritis Foundation so there's no direct relationship to arthritis so again for fire millage itself you know there's no damage to joints that being said if you have a lot of osteoarthritis maybe your neck or your back your knees or that's a constant source of pain that can intensify the the sensitivity to pain and all the symptoms of fibromyalgia now how did the Arthritis Foundation end up with farm al-jamal a of rheumatic disease in that a lot of sensation of our mouches all in the muscles and joints them and periphery and that ultimately kind of ended up in the world of Rheumatology ended up in the world of the Arthritis Foundation but that being said the truth is in a sense this really doesn't belong to anyone anyone medical specialty because this affects so many different parts of the body yeah so there's a lot of different support groups around and so a couple things about support groups so so one way I do it is through cognitive behavioral therapy groups and that's actually run here through the Arthritis Foundation means through sorry run here through the Langley Porter Institute or the UCSF psychiatry department they have a support group cognitive behavioral therapy group I should say for people with chronic medical conditions or depression which includes farm algin so that's one way to join a group that won't necessarily be just fired knowledge of that can be helpful there are other Arthritis Foundation might be running groups and you can check with them and then there's often a lot of different other there's a lot of websites in fire mileage and they might sponsor groups too the one thing I should say about just groups is that you have to be a little bit cautious when joining a Farm Alger group because get it's incredibly important that the group is supportive and reinforcing of positive thinking if you will as opposed to a group where everyone's just complaining about things you'll actually probably come away from the group feeling worse so proceed with caution yeah yes oh yes this is the were the previous terms to fire Malcolm and there's a lot of nonspecific terms in the history honestly I don't know the history of it but what most definitely everyone settled on is the term fibromyalgia it gets a little bit tricky trying to track things down in the distant layer because it was often called other things but but yeah everyone's pretty much settled in fire manager now yeah oh so the question is you know well do am i genetically predisposed out predisposed and my grandmother she had rheumatism and what did that mean and we'll never know yeah so you had a question yeah so the question is so methadone which of course is a narcotic so overall as a drug I'm I'm a fan of methadone of course methadone is known as being the drug that that heroin abusers get shifted over to stop using heroin but in fact it's it's a fantastic narcotic because very long acting with a very steady effect now that being said in general my experience has been in people farm al Joe is that they need higher and higher doses to control pain levels so yes methadone probably will work to control pain but people will probably need higher and higher doses and then start running into the side-effects of higher and higher doses northark what I use is instead of a different narcotic it's a funny question the answer is you know I'm saying well I wouldn't use one but uh I sure if I was going to turn to one trip yeah yes and I'm glad you asked that so question about whether fire male just shows up in bets so absolutely I meant to it it just pains me every time we send guys into harm's way because I know and the data is that perhaps even a third of them will experience PTSD and other problems that kind of lead into these kinds of problems and so every time we send people abroad and I'm not saying that you know it's not necessarily to do that but I know that the impact on the lives those guys is going to be profound and may be lifelong yeah that's a big deal yeah so how long ago was it described or discovered that fire Malchus is attributed to this pain sent a sensitization syndrome it's a hard question to answer with with almost any medical problem there needs to be kind of an accumulation of data a sort of development of a body of evidence before people begin to change the way they think about it and particularly with something as tricky as this that had to be a development of a lot of data so a lot of that stuff was developed in the late 80s but really kind of came into to more heavy development of understanding neuroscience in the 1990s and the best studies have come in the or in the mid-2000s so I think the idea started being tossed around probably 10 to 15 years ago and more heavily accepted in the last five to ten years yeah that it that's it all right thank you thank you all

Channel: University of California Television (UCTV)

Views: 692,319

Keywords: fibromyalgia, pain management, Rheumatology

Id: aprthkmlE2Q

Length: 87min 22sec (5242 seconds)

Published: Thu Feb 16 2012