It is very unfortunate that many doctors don't know what is fibromyalgia. It is not taught in
medical schools, even though it affects 5% of the general population. This may be
because fibromyalgia was not well described, and nobody understood what was going on,
and it has really been in the last 20 years that fibromyalgia has been understood and described,
thanks to the invention of functional brain imaging that we now understand
and we can see fibromyalgia. So, today we are going to talk about it.
Welcome to this YouTube channel. Let's talk about pain. At the end of this video, you may leave your
comments, questions, and suggestions for future topics. Remember that this YouTube channel is not
intended to provide individual patients’ advice, but rather, it's a way of providing education
about chronic pain, and if you think that you have a condition that is causing you chronic,
pain please talk to your doctor to get a proper diagnosis and a treatment plan for you. Today,
we're going to talk about fibromyalgia. And what is fibromyalgia? Fibromyalgia
is a condition that the person has pain all over the body. So I usually give a body pain
diagram for my patients to complete, and I ask them to paint all the areas that they
have pain in their body. And when someone completes a pain diagram like this one,
that they mark the back, in the front, the upper parts, the lower parts, the trunk,
and the limbs, almost every part of the body, this is indicative of fibromyalgia.
But this is not diagnosis of fibromyalgia. You still have to exclude all the conditions that
could be causing fibromyalgia, such as an autoimmune disease, or sickle-cell disease,
some chronic inflammatory disease, arthritis or muscle inflammation, we call this Myositis.
So basically, fibromyalgia includes this pain all over the body, but also exclusion
of other things that could be causing this. So Fibromyalgia is a diagnosis of exclusion.
The diagnosis of fibromyalgia should be made by a doctor that knows what is fibromyalgia,
but not a lot of doctors know what fibromyalgia is, so maybe some doctors need to watch this video
and learn a little bit more about fibromyalgia. The current reviews of diagnoses of fibromyalgia
say that it is not like a yes/no, you have or you don't have fibromyalgia. But it's more like
a spectrum of symptoms and signs. So, some people may have some signs of fibromyalgia,
and others that will have a lot of signs and symptoms of fibromyalgia.
Fibromyalgia is a disease of the pain system. In another video that I made, I explained more
what is the pain system, and explained that this is more like the alarm system of a house. That's
the analogy that I use, and the alarm system of a house can be malfunctioning. The same thing can
happen with the pain system in your body, and the alarm system of our body, the pain system,
is actually to trigger when something's wrong. So, then, we can go in fix it, but if it's the
alarm system that is broken or malfunctioning, then we cannot go and fix the knee, or the head,
or the abdomen, we need to fix the pain system, and that's what we need to do with fibromyalgia,
we need to fix the pain system because that's where it is malfunctioning. In the majority of
cases fibromyalgia starts as a very vague and hard to define pain in a body part sometimes
this patients the first symptoms of her mouth may be an abdominal pain and they are seen by
gastroenterologist and they're giving the diagnosis of irritable bowel syndrome and
then many years later they have been all over their body other patients they may start with
pelvic pain and they are seen by gynecologist or urologist they are giving the diagnosis of
chronic prostatitis or Vulvodynia or Interstitial Cystitis. Other patients,
the pain starts in the face and they are seen by dentists and today may be giving the diagnosis
of temporal mandibular joint dysfunction, but what characterizes fibromyalgia is that the pain
starts as a vague sensation nobody finds what's wrong and then in between a few months or years
then it's affecting the whole body. In fact all of these conditions they have the same thing in
common with fibromyalgia; all of them are a dysfunction of the pain system or the alarm
system of our body. So what is wrong with the pain system of our body to cause fibromyalgia?
With the invention of functional brain imaging, in the last 20 years we have been able to see and
study the brain of people with fibromyalgia and understand and really find the causes of what's
wrong with the paint system and help these people who have fibromyalgia. One of the things that we
know about fibromyalgia is that the volume dial of the pain intensity is turned up. This means
that in people with fibromyalgia they would feel pain when it's they are stimulated with
something that in a normal person that doesn't have fibromyalgia, it doesn't hurt. In a person
that has fibromyalgia they are more sensitive to light touch and to sensations that I would
not cause pain normally. We call this nociplastic pain or central sensitization and it's one of the
hallmarks of fibromyalgia and it's related to a neurotransmitter in the pain system and that
is called glutamate. The second thing that happens is that it's not just the pain that
is more sensitive it's not just the diel or pain that is turned up, but it's the diel for
almost all sensory inputs or sensations that we can have such as heat and cold, a bright light,
a loud noise or even some chemicals that's not uncommon that people with fibromyalgia over time
they develop some chemical sensitivities and they start having side effects to medications
that they didn't have before and they start getting more sensitive to substances around
the house or even smells of detergents and things that are they were usually they were not usually
sensitive but now they develop this sensitivity. Third, because the brain is sensitized we call
this central sensitization all the areas of the brain are also affected in a person
that has fibromyalgia for example the areas that control the mood, the areas that control asleep,
concentration and it's very common symptom that people with fibromyalgia complain of depression,
anxiety, lack of concentration, memory problems, fatigue. Also because the brain has been trying
to deal with this pain, it has been shown that the brain of a person with fibromyalgia
is loaded with their endogenous opioids our body produces our own opioids like dynorphins,
enkephalin, endorphins. This opioid is endogenous opioids they are supposed to suppress pain and we
have in our body a system that suppresses pain we call this the descending because it's going down;
descending inhibitory pathways. We now know that in a person with fibromyalgia they are
not able to activate those descending inhibitory pathways and this pathways are highly dependent on
serotonin that's the neurotransmitter responsible for the descending pathways and there is a lack
of serotonin in these pathways of a person that has fibromyalgia. So a lot of patients ask me
is there cure for fibromyalgia? And my answer is unfortunately no but it's like having a diagnosis
of diabetes or hypertension; once you have the diagnosis you have for the rest of your life
but like diabetes and hypertension, there are many things that you can do may not involve medication
can be diet and exercises that can help to control the symptoms. Some people may need medications for
fibromyalgia but not everybody. So the same thing is with for fibromyalgia, we don't have
a cure but a lot of ways that we can help people to manage and control their symptoms and leave a
good quality of life even having the diagnosis of fibromyalgia. So let's talk about the treatments
for fibromyalgia. The way we fix the pain system is using a interprofessional multidisciplinary
team of people because we look at the person as a whole. The person with fibromyalgia has
some sort of disabilities and we call this the invisible disability because a lot of people who
tell the person “well there's nothing wrong with your body”, “you must be inventing this pain”,
“this pain is in your head”, that's not true. There is really, really pain. There is functional
brain imaging that shows that the person that has fibromyalgia something abnormal in the brain but
it doesn't mean that the person is inventing. So we need to treat the person with fibromyalgia with
a rehabilitation approach which is looking at the whole person and rehabilitating which means
bringing the person to normal life, bringing the person to enjoy life. This is the rehabilitation
approach. The first thing that we do to fix the pain system is education. We to explain to the
patient what is wrong with their body a lot of patients with fibromyalgia have been told that
they were creating inventing this pain because there was nothing wrong with their muscles or
their joints. That's not true so we spent a lot of time explaining to patients what is
fibromyalgia what is wrong with the pain system and how can we fix the paint system. Education
is part of the treatment. Then the second thing that we do for treatment of fibromyalgia includes
self-management strategies. This is teaching the patient to manage their own symptoms to
give them the tools that they need to manage their pain. So what there are a lot of patients groups,
community resources, videos, books, groups that people can go and learn like in classes in groups
how to manage their symptoms of fibromyalgia like exercises, sleep hygiene, healthy eating,
pacing, setting realistic goals, scheduling fun in your life, a relaxation of the body and mind,
a mindfulness meditation, social interactions, how to manage work and life balance. All of those
things are topics that are taught in this group or books or videos that talk about self-management of
a person with fibromyalgia. But for me the most exciting discovery in the last couple of years
with brain imaging and other research has been deemed the discovery that movement exercise is
an excellent method to retrain the pain system. In fact people with fibromyalgia in muscle pain
in general, they need four types of exercises. I called this the SSAR. They need stretching of
the muscles, they need strengthening, aerobics exercises, and relaxation exercises because when
a person start moving the body and doing this kind of exercises they are retraining the pain system
to feel pain normal again and not to feel pain when they're not supposed to feel. And the person
has to start low and increase is slow because they have not probably a person with fibromyalgia has
probably not been doing exercise for a long time and if they start doing a lot of things it's going
to hurt initially. So they have to start and pace and start very low and increase it slowly in the
amount of exercise that they do. But because fibromyalgia is not only about pain, it's also
about other symptoms, we always recommend a person that they need to combine movement with some sort
of mental health therapy to help them with the problems of mood, anxiety, sleep problems, lack of
concentration, fatigue, one of the therapies that have been very, very helpful in there's a lot of
evidence showing that it works for fibromyalgia called cognitive behavior therapy or CBT but
there are also other modalities of counseling or therapy that has been shown to be very efficacious
for fibromyalgia. In last, let's talk about medications. As I mentioned the fibromyalgia is a
disease of the pain system and it's in the central nervous system so we need to use drugs that were
acting the central nervous system. One of the problems of fibromyalgia is that there's a lot
of excitation of the painful east painful stimulus and pay from sensations that go to the brain and
these are dependent on glutamate. So we sometimes we prescribe substances that will block this
sensations and these are things like a gabapentin or pregabalin that decrease the glutamate action.
Second, we also need to stimulate the descending inhibitory pathways that will inhibit the pain in
an effective manner and as I mentioned before this pathway is dependent on serotonin so we need to
increase serotonin in the brain and things that do this are enter the anti depressants usually they
tricyclic antidepressants like amitriptyline or nortriptyline they increase serotonin and
also the other antidepressants that we call SNRIs and one of them is duloxetine or even venlafaxine
they increase serotonin in the brain helping this descending inhibitory pathway. And third, because
there's a lot of the endogenous opioids around the brain and they're not helping to solve the problem
of brain of the pain we have some medications that can reduce the activity of these endogenous
opioids one of them is an oral naltrexone. A naltrexone is the oral form of naloxone, therefore
we don't give up you its exogenous opioids like use of opioids or patches for people who have for
fibromyalgia because then you would be increasing this opioids in the body and making the pain get
worse because opioids in a brain of a person with fibromyalgia they act like a glutamate,
causing more central sensitization so we certainly don't want to do that. In last, I have been asked
a lot about cannabis and cannabinoids for fibromyalgia I did another video that talks
only about cannabinoids in regards to fibromyalgia there is absolutely no Studies at this point maybe
in the future we'll have more research and studies telling us that if it's good or not. I have some
patients that they use CBD oils for fibromyalgia, some people tell me that it's helpful some people
tell me that it didn't make any difference so at this point we don't know much about cannabis
or cannabinoid for fibromyalgia. I see a lot of people that rely only on medications as the only
thing that they do to treat their fibromyalgia, that's also not healthy. We need to include all of
the other modalities movement, mind-body therapy, physical modalities, manual therapy, all of those
things are very helpful to prevent the progression of fibromyalgia and I usually tell patients
we need to put a lot of tools in your toolbox to manage pain because if the only tool that you have
this medication, that's not a good toolbox, you need to have many other options in your toolbox.
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