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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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Fibromyalgia & Other Pain Controversies

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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

Fibromyalgia other pain controversies


  • 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?

Fibromyalgia other pain controversies


  • 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


    • 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?

  • Fibromyalgia other pain controversies


    • 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



    • 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


    • 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

    Chronic stress response cycle

    Chronic Stress Response… Cycle?

    Vagal nerve afferents

    VagalNerve Afferents

    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



    • 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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