Let’s put to the side the past stigmas associated with Fibromyalgia. For many years a majority of physicians did not believe in Fibromyalgia and there are still a few physicians who refuse to recognize or treat Fibro patients. While rounding on patients in the hospital, I have overhead a colleague label Fibromyalgia as the “depressed, overweight, middle age, housewife syndrome”.
Luckily, the medical community is finally coming around to recognizing this chronic pain condition. Current Fibromyalgia research and treatment philosophy resolves around the theory of Fibromyalgia being a mixed component of a central nervous system dysfunction with a chronic myofascial component.
Fibromyalgia is a diagnosis of exclusion, make sure to have labs to rule our other connective tissues diseases first, like Rheumatoid Arthritis, before accepting the Fibro diagnosis.
Below is a list of recommendations we make to all of our Fibromyalgia patients on there first visit:
- Every Fibro patients needs a sleep study to treat any underlying sleep disorders that will directly complicate pain.
- Treat any underlying depression, this can not be understated! Whether with counseling, psychiatric treatment, meditation and if needed medication
- Check underlying vitamin deficiencies that can complicate pain, including Vitamin D, Vitamin B12, Vitamin B1, Vitamin B2 and Vitamin B6.
- Start a daily home exercise/stretching program, Fibro will worsens with inactivity. We have heard every argument from patients that it hurts to much to exercise but it is critical to do some daily stretching/exercise routine. We recommend low impact yoga, pilates, tai chi, aquatic therapy.
- Eliminate all soda’s immediately, totally toxic and can increase inflammatory levels in the body complicating pain.
- Restrict the ‘nightshade plants’ from the diet to limit their inflammatory related issues.
- Limit yeast foods, so many of our patients struggle with this one but it will dramatically improve your energy
- Work with a local physician and consider one of the FDA approved medications for Fibromyalgia: Cymbalta, Lyrica or Savella.
- Consider a workup for gluten allergy.
For motivated patients we encourage them to study and incorporate mindfulness into their daily routine. Mindfulness is the psychological process off bringing one’s attention to experiences in the moment. It is best accomplished with training and the practice of meditation. Mindfulness interventions are effective in reducing rumination and worry. Rumination on one’s pain or illness exacerbate depression and underlying anxiety conditions. A classic example is with our Fibromyalgia patients, they commonly ruminate on the condition and identify themselves as ‘Fibro’ instead of focusing on a more positive aspect of their life.
Classic mindfulness treatments we recommend to patients include a very basic mindfulness meditation where a patient sits and quietly focuses on their natural breathing. The patients are taught to allow thoughts to come and go without any judgement, simply allow the thoughts to dissolve away and then focus back on their breathing. A simple 3-5 minutes per day will start to show dramatic benefits in as little as 2 weeks as patients learn to wipe away anxiety and help to distract from the negative effects of pain on the mind.
A few apps that we have found helpful for patients to practice mindfulness include: Headspace, Aura and the app Stop Breath & Think.
As a patient incorporates a mindfulness approach to their daily routine, pain levels decrease, anxiety decreases, empowerment increases and patients inch closer to a cure for their pain.
Carbohydrates make up the majority of the calories in many Americans’ diets. Carbohydrates are a type of macronutrient which provide the body with energy. Grains such as bread, cereals, pasta and rices are all types of carbohydrates. Carbohydrates also come from fruits, vegetables and the natural sugars found in dairy products.
Some quick education on Carbs can help patients to have a better understanding of foods to be wary of in fighting chronic pain. Refined carbohydrates, such as white bread, white rice, cookies and candies, sodas, contain very little benefits to our general health. Refined carbs are low in fiber, vitamins and minerals. Complex carbohydrates such as whole wheat bread, brown rice, broccoli and asparagus, are rich in dietary fiber, help to stabilize blood sugar levels and are better choices for pain patients. Complex carbohydrates also contain high levels of vitamins and minerals.
Interesting enough most chronic pain patients, specifically Fibromyalgia, patients tend to have more frequent cravings for carbohydrates than healthy individuals. When patients give into the simple carbs they can enter a hypoglycemic state, or a sudden drop in blood sugar, perpetuating the fatigue and pain of fibromyalgia and other chronic pain conditions.
Cutting out all carbohydrates from the diet is not recommended, since they do serve an important function in the metabolic process. Instead, we recommend cutting out all refined carbohydrates and choosing complex carbohydrates to make up 30-40% of your daily calorie intake.
These changes can significantly decrease inflammatory levels, improve energy and decrease pain.
To help find a ‘cure’ for you pain, we require our patients to become proactive. This requires patients to take the initiative to improve their situation. Instead of letting your current circumstances be the driving force of determining your future we help patients to determine their choices and act to improve their situation instead of only reacting.
We help our patients realize that even when they feel they have limited choices or little hope there is always a direction that allows the patient to be in control of their pain and therefore their outcome. We teach our patients that they get to choose how their pain and conditions define them. Patients that currently feel helpless are allowing their circumstances and conditions to control them. For example a helpless patient may respond with “there’s nothing I can do about my pain”. We teach our patients to focus their time and energy on things they have control over. For example, our patients get to decide if they will wake up and do something productive today. They get to decide if they will interact positively with their family despite how their pain is making them feel. We help to teach our patients ways to empower their situation. That feeling of empowerment propels patients to gain more and more control of their pain. Focusing on items we do control instead of the items we can’t control help to reduce stress levels which decrease anxiety and help our patients to better cope with their pain.
We teach patients to eliminate certain phrases including: “I can’t”, “I must”, “If only”, ‘there’s nothing I can do”. We help patients break the handcuffs of negativity that surround and influence their painful condition.
We help patients look at alternative so that they can instead take a different approach and be in control, only then can you find a ‘cure’ for your pain.
A significant amount of chronic pain patients deal with chronic low back pain. This is a massive topic that we begin to cover in this introductory article and will dive deeper in future articles. In this article we will discuss mechanical back pain which is separate from discogenic back pain. The two main types of mechanical (axial) back pain are Sacroiliac Joint Dysfunction (SI Dysfunction) and Lumbar Spondylosis.
The Sacroiliac Joints are a pair of joints as the iliac crest attaches on either side of the sacrum, which is the bone just above your tailbone. Patients with SI pain can have bilateral or unilateral pain. SI joint patients typically have trouble walking up inclines, getting up from a seated position and the pain is a complex combination of instability in the SI joint, inflammation and many times associated piriformis tendon involvement. There are physical therapists that spend their entire careers focused on treating SI joint pain and the therapy for SI dysfunction is completely different than physical therapy for common low back pain. When patients plateau with physical therapy we have found tremendous success in targeted interventional injections to the SI region. We will typically begin worth a combination of cortisone and anesthetic to work as both a diagnostic as well as therapeutic treatment. Patients who experience only limited benefits from this treatment are then likely candidates for prolotherapy to the region which is a specific series of injections designed to harness our body’s own natural healing process. This is particularly helpful in patients who have an underlying instability in their SI joint.
Lumbar Spondylosis is medical terminology for pain emanating from the facet joints in the vertebrae. The facet joints run on the back portion of the spine and we describe them as the ‘knuckle’ joints of the spine. They allow the spine to twist and move and are classic causes of back pain anywhere along the spine but a very common cause of low back pain. Classically, patients with facetogenic back pain describe pain with extension or rotation activities, standing to wash dishes and lifting activities. Many time patients will describe a catching sensation or will describe back pain that runs from the spine out along the belt line. As always we recommend a trial of physical therapy and various other modalities we have discussed in previous articles. If patients fail all more conservative treatment we will consider facet joint injections. If the facet joints injections help but are only temporary we will then consider Radiofrequency Ablation injection to the affected facets. RF injections have a typical period of relief from 6-12 months.
The goal of these treatments are to improve function, decrease pain and hopefully avoid surgery. As always, diet, exercise, weight management, stress reduction are all integral in helping to improve any treatments.
Meditation is an effective tool to help avoid additional prescription medications and help cure pain. Meditation can rewire the brain’s pain circuitry. Neuronal pathways within the brain get programmed every time you expect pain to occur — in time, less and less stimulus is needed to trigger the pain reflex. Eventually, the simple thought of pain becomes the true source, not necessarily the ailment itself.
Meditation can unhook your emotional reaction to pain. Our patients can get stuck in a brutal feedback loop, without even realizing it. Their anticipation of pain creates stress, stress leads to physical tension within the body — especially near the painful area, which ultimately leads to more pain.
Meditation teaches you how to emotionally detach from your negative thoughts and physical sensations, where you no longer expect pain, nor resist it when it does occur.
Meditation can also help us treat our natural flight or fight response to pain which can be abnormally triggered in chronic pain patients. The flight or fight increases cortisol stress levels. Elevated stress levels increase blood pressure, increase inflammatory markers and increase pain. Meditation helps to reduce these harmful stress hormone levels.
Meditation can also boost natural endorphin levels which act as a natural pain reliever, decrease cortisol levels and allow patients to be in control of their pain
Aquatic therapy is an excellent form of physical exercise which can be a critical component to helping patient’s find a ‘cure’ for their chronic pain. Water is one of the oldest mediums of physical treatment with both physiological and psychological benefits. Water provides an environment where one can move and exercise with little or no pain which can significantly lower stress on the joints. The buoyancy provided by water allows chronic pain patients the ability to move with less effort. Exercise in water allows for improved flexibility and ease of stretch. The activity of water therapy also helps to boost natural endorphin levels a key to healing. Staying active in a less stressful controlled water environment improves a patient’s quality of life, improves mood and can decrease a patient’s fear of pain.
Aquatic therapy represents a positive, rewarding and useful activity for enhancing mood. It can help build hope and provide the motivation to continue activity. Aquatic therapy provides an environment where patient’s can focus on their abilities, not disabilities. As we have mentioned in previous articles, becoming an active participant and enrolling in aquatic therapy is a positive decision our patients can make to decrease and control, possibly even cure, their pain.