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Raouf (Ron) Gharbo D.O. VOMA Spring Conference 2010 Williamsburg, Virginia. Fibromyalgia & Other Pain Controversies. Bias. A personal and unreasoned judgment. Merriam-Webster One commercial break for our sponsor Not looking for more Fibromyalgia referrals. Pain Management.

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raouf ron gharbo d o voma spring conference 2010 williamsburg virginia
Raouf (Ron) Gharbo D.O.

VOMA Spring Conference 2010

Williamsburg, Virginia

Fibromyalgia & Other Pain Controversies

slide3
Bias
  • A personal and unreasoned judgment.
    • Merriam-Webster
  • One commercial break for our sponsor
  • Not looking for more Fibromyalgia referrals
pain management
Pain Management
  • What is your definition of Management?
  • Does it imply holistic approach?
  • Not recognized by America Board of Medical Specialties
  • National and individual outcomes?
  • Interventionalist
  • Isn’t Fibromyalgia a pain syndrome?
slide5
Pain
  • The American Academy of Pain Medicine– “An unpleasant sensation and emotional response to that sensation”
  • The real issue is anguish/emotional suffering
      • Barbuto; Am. J. Phys. Med. Rehab. 2008
  • Anxiety is a fuel for pain
  • Insomnia is a fuel for anxiety and visa versa
  • Fear , anger, unrealistic expectations are fuels for anxiety
anxiety
Anxiety
  • A painful or apprehensive uneasiness of mind usually over an impending or anticipated ill
  • Inconvenient to treat
          • Friday afternoon breakthrough anxiety-fear
  • Lifestyle choices
  • Atypical Chest Pain?
  • Medication efficacy
  • Avoidance is a coping strategy
  • Somatization is one avoidance strategy
  • Why don’t so IT pain pumps seem to work?
slide7
Fear
  • An unpleasant often strong emotion caused by anticipation or awareness of danger and accompanied by increased autonomic activity
  • The amygdala (emotional memory center) is activated and initiates the flight or fight response
  • Disabled Distressed Rats: Fear of re-injury and pain are major causes of disability
anger
Anger
  • A strong feeling of displeasure & belligerence
  • Anger is a emotion when threatened
  • Frymoyer & Bigos Studies 1990’s
      • Anger towards direct supervisor
  • Why don’t we see many angry fibromyalgia men?
fight or flight response
Fight or Flight Response
  • Amygdala
  • Pituitary – sympathetic response
  • HPA axis: Adrenals release of cortisol
  • Systemic & Cardiac Adrenaline effects
  • What about chronic stress
secondary gain or is it fear or both
Secondary Gain, or is it Fear? Or both?
  • Chronic somatically focused LBP
  • Fear of Re-injury? Job loss?
  • Who’s fault is it if our patients are afraid of degenerative arthritis, fibromyalgia or discogenic pain?
degenerative arthritis v osteoarthritis
Degenerative Arthritis v. Osteoarthritis
  • Bradykinesia & kinesophobia signs of F.O.S.?
  • “Your spine is going to crumble into a fine dust”
  • Fear of reinjury
  • Age appropriate changes
  • Wolfe’s Law and spine stability
  • Straightening of cervical lordosis?
fibromyalgia syndrome
Fibromyalgia Syndrome
  • Does it exist?
  • Syndrome: A set of symptoms occurring together; the sum of signs of any morbid state
  • Fibromyalgia is different from good ole American chronic low back pain
          • Dicle Univeristy Physiatry
fibromyalgia what are you going to do
Fibromyalgia: What are you going to do?
  • Oath to treat only convenient patients that keep us on schedule?
  • To validate or not to validate? Hamlet
      • Validate Pharma commercials?
  • Your choices:
      • Scoot quickly out of room & be afraid of every f/u
      • Dump on your colleagues
      • Take on their burden and risk your own survival?
      • Kubler-Ross 5 stages of provider grieving
      • Accept to take on their treatment, but not their burden
stereo system volume dial
Stereo System Volume Dial
  • Hearing dial
  • Pain dial: elevated levels of substance P in muscle tissue
  • Awareness/Proprioception dial
manage the fibromyalgia visits
Manage the Fibromyalgia Visits
  • Printed website handout
  • Second visit: 30min f/u
  • Listen and assess motivation by quality of Q’s
  • Answer questions
  • Validate with eye contact & limit to office, move on, in office revalidation, move on, in office revalidation, move on
  • Sleep habits
  • TPI & Nutrition covered in another lecture
some useful home exercises
Some Useful Home Exercises
  • Passive Trapezius muscle stretching
      • Breathing, awareness and slowing down
      • High stress reduces efficacy of medications
  • Active Cervical ROM
      • Sand down Ca++ deposit rough edges from lack of use
medications
Medications
  • Rational Polypharmacy?
  • Muscle Relaxers??
  • Dantrolene Sodium
  • Cyclobenzaprine & TCA’s
  • Gabapentin & Pregabalin(Lyrica)
  • SNRI’s
  • “what if that doesn’t work?”
a word from our sponsor on snri s
*A Word From our Sponsor on SNRI’s
  • Two SNRI’s have been shown to reduce pain in Fibromyalgia
    • -Duloxetine-Cymbalta 1 to 0.2 S:N affects
    • -Milnacipran-Savella - 1 to 3 S:N affects
  • Only medication to increase function(SF36) at 3 & 6 months is Milnacipran
      • Mease 2009 N=888 & Clauw 2008 N=1196
  • Renal excretion
  • >10 years of safety
  • Weight neutral at worst
new topic somatization
New Topic: Somatization
  • Somatizing patients without comorbid depression or anxiety disorder. N=290
  • Results extrapolated to national level 256 billion/yr in medical care costs are attributable to the incremental effect of somatization alone.
  • Approximately 2x the annual medical care costs of nonsomatizing patients.
        • Barsky; Arch of Gen Psychiatry 2005
  • Remember costs come with procedure and medication risks
avoidance behavior
Avoidance Behavior
  • Psychiatry DSM criteria and definitions
  • Somatically Preoccupied
      • Spitzer JAMA 1991
  • The real issue is anguish/emotional suffering
      • Barbuto Commentary: Am. J. Phys. Med. Rehab. 2008
somatically focused lbp
Somatically Focused (LBP)
  • Maladaptive avoidance behavior that results in a disparity between physical impairment and function regardless of organic pathology
somatization enablers
Somatization Enablers
  • Entities that validate or magnify minimal organic impairments reinforcing maladaptive avoidance behavior
examples of somatization enablers
Examples of Somatization Enablers
  • Opioids
  • Monthly vicodin merry go round
  • Discogenic pain
  • Discograms
  • 5th vital sign
  • Lumbar scars
  • Interventionalists
  • (Myopic ones)
discogenic pain controversy
Discogenic Pain Controversy
  • Pain is not a diagnosis
  • Low back pain with or without leg pain
  • Characteristics of a good screening test
      • No false negatives
      • Reliable outcome measures (pain?)
      • Inexpensive
      • Noninvasive
      • Well defined condition
      • Treatment has good outcomes
2000 volvo award winner
2000 Volvo Award Winner
  • 45 asymptomatic patients with normal psychometric testing
  • 143 discs evaluated by MRI
  • 13 discs showed HIZ on lumbar MRI
  • 9 abnormal on discography
      • Carragee, Spine 2000
  • Please don’t ever send any of my family members for a discogram
what are the rules
What are the Rules?
  • Primum non nocere: Do No Harm
  • Beneficence vs. Do No Harm?
      • “I believe my patients”
      • “They came to me to do something”
      • Acute pain model simply doesn’t work for chronic somatically focused low back pain patients
  • Protect your patients against willful myopia
holistic care for drug seekers
Holistic Care for “Drug Seekers”
  • Intelligent disciplined diverters -criminal act worthy of discharge
  • Substance abuse -medical condition with specific patterns worthy of medical treatment, appropriate opioid weaning, and a measure of empathy
  • Anxiety/Somatization-worthy of greater time & attention, rational opioids and protect from unnecessary risk
my painful principles to stay out of trouble
My Painful Principles:To stay out of trouble
  • No dumping
  • “I do not prescribe” is not acceptable if you maintain a DEA#
  • Lying is just a symptom of abuse
  • Baseball rule
  • One Mulligan
  • Maintain good habits without escalation (be effective, not right)
  • No gotcha
  • Pseudoaddiction
  • “Not all pain can be relieved”
  • Some patients not ready change
  • Pain and suffering often look the same-Barbuto
  • Opioids can validate and enable
  • A single provider can’t….
what s reasonable
What’s Reasonable?
  • Legitimate diagnosis documented and communicated
  • Stable dose and mood
  • No major workup or decline of condition expected
  • Documented functional gains for nonmalignant pain
  • May follow up prn for dose escalation
heart rate variability biofeedback mccraty american journal of cardiology 1995
Heart Rate Variability BiofeedbackMcCraty: American Journal of Cardiology 1995
  • Slight increase HR with inspiration & slight decrease with expiration
  • Habituate gratitude
  • Less hopelessness then less helplessness
summary
Summary
  • Do No Harm
  • Protect your patients
  • Don’t be right and escalate, be effective
  • Listening is counseling
  • Validate Fibromyalgia with eye contact and move on
  • Don’t validate avoidance behavior
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