Episode 15: Fibromyalgia - A Basic Approach to Management

This episode describes Dr. Karmy's approach to patients with fibromyalgia. He delves into what are the treatments he finds the most helpful and the pros and cons of each approach.

Follow our social media:
Instagram
https://www.instagram.com/karmychronicpain?igsh=cHZycXdzeGhqN2Zn
Facebook
https://www.facebook.com/profile.php?id=61550237320641&mibextid=dGKdO6

Learn more about pain management treatments offered at our clinic: https://karmyclinic.com/

Chapters

• 1:00 Differences between Fibromyalgia and Myofascial Syndrome
• 2:31 Contributing Clinical Factors (Genetics, Triggers) and Central Sensitization Disorder
• 7:40 Pain Management Approaches (Exercise, Psychotherapy, Medications)
• 10:20 Types of Medications
• 12:42 Advantages and Disadvantages of Trigger Point Injections and Peripheral Nerve Blocks
• 14:18 Other Procedures (Botox, Cortisone, PRP)
• 16:17 Response Rates

Transcript

Dr Karmy: 0:00

Also, it is important to discontinue medications that are not working, because otherwise patients with fibromyalgia and chronic pain end up being like little pharmacies with five different tablets that may help, but none of them actually helping. The more medications you take, the more likely you're going to experience interactions between them and side effects.

Raveena: 0:32

Welcome to Chronic Pain Chronicles with Dr. Karmy, where we delve into a complex and widespread pain disorder that impacts millions worldwide, known as fibromyalgia. I'm Raveena, your host and advocate for understanding the multifaceted aspects of this pressing issue. As we explore the causes, symptoms, and innovative treatments for fibromyalgia, we're joined by Dr. Grigory Karmy, an expert in pain management with over 20 years of medical experience.

Dr Karmy: 1:02

This is Dr. Karmy and today I wanted to discuss fibromyalgia. Fibromyalgia is a fairly common disorder in my practice and there's often overlap between something called myofascial pain syndrome and fibromyalgia. Typically, fibromyalgia presents with very, very widespread pain. It's neck, it's both shoulders, it's mid back, it's lower back, sometimes also arms and legs. Headaches are very common. Temporomandibular joint syndrome or jaw pain is common. Irritable bowel syndrome is fairly common in these patients. Also, they often have a lot of fatigue and difficulty sleeping. They complain of quote unquote fibro fog, which means that they will have difficulty with memory and concentration, and often their mood is impacted as well. While we don't fully understand. the causes for development of fibromyalgia. We do understand some things about it. First of all, there seems to be some genetic predisposition. In other words, patients with fibromyalgia often will have a family member with either fibromyalgia or another form of chronic pain. Second of all, often there is a trigger. That starts it. The most common trigger is physical trauma, in my experience. Think of car accident or slip and fall. Often the pain starts out in fewer areas, but over time spreads throughout the whole body. Other less common triggers include extreme emotional stress, a virall infection, such as COVID. Typically, by the time the patient comes to me, they have had pain for at least six months. The pain is usually constant, it's not just with activity. And the types of pain will vary, everything from spasm, to burning, to cold, to shooting, many, many different types of pains. For many patients, the range of movement is preserved, but not for everyone. So this is the typical clinical picture. One thing I find with some of the patients with fibromyalgia is they become preoccupied with the source of the pain. They feel often that given how severe the pain is and how long it has been present and how much it limits them, there has to be an underlying anatomical abnormality, and they spend extensive amounts of time time undergoing various tests including MRI scans, x rays, ultrasound scans, and so on. It is not wrong to do these things and can sometimes actually be helpful. However, to the extent that we understand fibromyalgia we think of it as a central sensitization disorder. In other words, what happens is often there is a trigger, such as a car accident or a fall. An area becomes painful because of tissue damage. But then over time, as tissues heal, there are some permanent changes in the nervous system at multiple levels. The nerve endings that go to the injured tissue, the spinal cord, even the brain. These changes seen are anatomical changes, there's some suggestion of biochemical changes, The end result is that when the tissue is fully healed, the nervous system continues to receive pain signals. It becomes hypersensitive, and over time, often the area of these hypersensitivity becomes larger sometimes to encompass the whole body. So in other words, the problem is more of a chemical change at the level of neurotransmitters and maybe microscopic change at the level of individual nerves and how they connect to other nerves via synapses and less due to the big sort of abnormalities you see on x ray or an MRI scan. Having said all that, often patients will have minor or sometimes more significant abnormalities on various investigations and they are quick to try to correct them surgically because the pain is so severe. More often than not, when they end up with surgery, the response rate is low and after the surgery, the pain is as bad as before the surgery and sometimes worse. What are some of the approaches to management of this condition? Like any other form of chronic pain, there is a lot of trial and error involved, and also a great deal of variability of severity of the symptoms. For patients whose symptoms are relatively mild, often exercise program alone, give or take physiotherapy can make a lot of difference. Patients will often also try different types of psychotherapy, including cognitive behavioral therapy. In part because many of them have depression and in part because psychological approaches can actually help patients, either put the pain out of their mind or reduce the anxiety that often pain triggers. If those sort of initial approaches are not helpful, patients will typically end up on medications. There isn't really a single medication that helps all patients with fibromyalgia. In fact, response rates of these medications are relatively low. My sense is that any given medication has about 1 in 10 chance of helping. And by helping, I mean increasing the risk. pain reduction, not pain cure. Generally speaking, medications do not have long term benefits. If they work, and as I mentioned, chances for them working are about one in ten, typically they work while they're in your body. And as soon as you stop the medications, the pain will be back to where it was prior to starting. the medication. The only way to really have a long term benefit from taking medications is to use the pain reduction medications afford you to push your exercise program. If one makes muscle stronger, bigger, and more flexible, that will typically improve function, sometimes reduce pain, and these benefits will of course stay after you stop the medication. What types of medications are used in patients with fibromyalgia? Well, let me start by saying which ones are not used. Generally speaking, opioid medications such as Percocet, Fentanyl patches, et cetera, are not used in patients with fibromyalgia. The medications that are commonly used are pregabalin, or Lyrica, gabapentin, or Neurontin, Amitriptyline, or Elevel, Cymbalta, or Duoxetine. These are all preventative medications, in other words, these are not medications that are used whenever your pain flares, they're typically used every day, irrespective of what the pain is doing, and after two to four weeks, depending on the medication, patients may find that they don't have as many severe attacks of the pain. This also, of course, means that it is much harder to tell if the medication is helpful or not if the effects are a month or two months down the road. It's hard enough to remember what one ate a month ago, trying to remember what the pain was can be difficult. Some patients will keep a pain diary to try to help with that issue. Also, it is important to discontinue medications that are not working, because otherwise patients with fibromyalgia and chronic pain end up being like little pharmacies with five different tablets that may help, but none of them actually helping. The more medications you take, the more likely you're going to experience interactions between them and side effects. Other types of procedures, which in my experience can be quite helpful, include trigger point injections and peripheral nerve blocks. The limitation of injections is that it is a local treatment. Unlike tablets that go throughout the body to all areas of pain, injections will only treat the areas being injected. Nevertheless, often patients with fibromyalgia find that some areas hurt more than others. And therefore, if one can settle pain in the worst areas, often it will lead to overall improvement in function. The other advantage of nerve blocks and trigger point injections compared to, say, cortisone injections and some of the other procedures is that they are relatively safe, and they can be done more frequently than other approaches. In general, nerve blocks and trigger point injections can be done every week, if necessary, and therefore it allows physician to target one area of pain on one visit, and if the pain subsides, on the following visit try to treat a different area of the body. Botox injections can also be helpful, in particular for migraines, which often accompany fibromyalgia. I have used cortisone injections into the joints of patients with fibromyalgia. as well as platelet rich plasma injections and have found it helpful in individual patients. Of course, the problem with, Botox injections and platelet rich plasma injections is coverage. Let me make it clear, none of these injections help a hundred percent of patients. Generally speaking for any given injections, response rate ranges from 30 to 70 percent, and let me be also explicit that there's relatively little research on treating fibromyalgia with injections. So a lot of these statements are based on my personal clinical experience. I have seen on occasion patients also respond to medical marijuana but again just like with tablets the effect is very short term. One comment I'd like to make is that with all the interventions that we use in fibromyalgia one always weighs the benefits against any side effects that they are experiencing. Since none of these treatments are curative, if the benefits are relatively small and the side effects, let's say, dizziness or nausea or drowsiness are quite severe, there's no reason to continue the medication. In terms of prognosis, prognosis is quite variable. Some patients improve over time and even recover fully. In both situations, usually the recovery and progress is slow, taking two to four years or even longer. I have never seen a sudden recovery from fibromyalgia after a specific treatment or over the course of a week or two. So, some patience. stay the same and some patients actually deteriorate over time. Why such different outcomes? I am not totally sure. I do have some sense that perhaps patients who don't give up and continue to progress their exercise program in spite of having pain, patients who continue to, experiment with different treatment options, patients who find other ways of accomplishing their tasks in life, be it work related or home related or exercise related, rather than just waiting until the pain fully heals before trying to go on with their lives. These patients that don't give up tend to do better. What I'm not clear on is whether that is because their fibromyalgia is just less severe as a condition or whether because their persistence is what causes all the difference. So, although my advice is not very scientific. If I had one message, it would be to persevere. Thank you.

Raveena: 18:28

Thank you for listening to Chronic Pain Chronicles with Dr. Karmy, a podcast which explores chronic pain from a physician's point of view. In our recent episodes, we explore some of the most effective and commonly used approaches to managing chronic pain, including ketamine and lidocaine infusions, nerve blocks, and regenerative medicine approaches. In future episodes, we will also try to explore the causes of chronic pain, look at rare medical conditions, and understand where the field is going in the future. I am Raveena Aujla. Till next time. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.