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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


  • 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?


  • 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?

  • 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


    • 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

    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