Fibromyalgia: It's Real, It's Manageable, What You Can Do

This show is a UCTV presentation for educational and non-commercial use only, so I'm Andy Gross. I run the Rheumatology clinic here at UCSF and I would like to thank Dr. Chau and others for inviting me to be part of the UCSF Mini School of Medicine Pain Series and I actually asked to talk about our myalgia, so Let's start with this, so first of all, it's always important to point out, especially with pain, where there is such a lucrative pharmacological market that I have no disclosures about, no one actually pays me to do anything, so okay, this is

what

I'm going to talk about and these are questions I get frequently.

What is far from Belgium? How common is it? How is it diagnosed? It is

real

? I get that question a lot. Where does the pain come from? What causes it? What can I expect? I'm going to go further and how I deal with it, so we'll get to all that. let's talk about power magic, here we go, so I imagine a lot of people in the room know something about this, but for those of you who don't, I'm basically going to go over and describe

what

people often tell me and This applies particularly to women, men definitely get the run of the farm just as often as women, but men definitely get it.

We can come back later to talk a little more about symptoms for men, but for women, the hallmark of

fibromyalgia

is widespread pain, so it's just pain. throughout their body and they usually tell me that they wake up first thing in the morning and have a lot of pain, a lot of stiffness as the day goes on and they get going, things loosen up a little bit and people usually have a better time from midday to early afternoon, but as the day goes on people often tell me that the pain starts to get worse and worse, and they tell me that, especially if they've had a busy day, the pain actually gets worse every day. again, so usually in the early afternoon, if people have been out and running a lot of errands and things like that, they usually tell me that in the early afternoon they feel like they've been hit by truckers.

Then they need to just find themselves collapsing trying to get some sleep, but the second distinguishing feature of

fibromyalgia

is that people are rarely able to sleep well at night and almost always wake up feeling restless, so they often spend the night giving round and round. Although they feel like they need a break at five o'clock at night, it is nothing more than a respite from their discomfort and finally, after all that, people almost always tell me that they have an enormous degree of fatigue that they are just trying to recover. getting out of bed in the morning and getting up and doing anything is a huge challenge, so those are the three types of hallmarks: widespread pain, fatigue, and trouble sleeping, and I'll come back to that, in addition to that. , people often tell me it talks about a variety of other things and that's why I usually put out these figures like this and just work from the head down, so people often tell me that they have a hard time thinking about it over and over again. .

I hear about people who have a hard time concentrating and have a hard time remembering things and they just feel like they're in a fog all the time, a second thing people talk to me about often and all of these things are kind of a combination No one talks to me of all these things, but people often talk to me about some combination. For some people, it is a very bad headache for some people. It's a pretty bad jaw pain. TMJ pain. For some people, quite severe chest pain. Doctors can't find much. People often have intestinal problems which are often described as functional bowel problems or oral bowel syndrome.

Constipation or loose stools or alternating back and forth with a bloated feeling. A lot of discomfort, especially if people eat the wrong thing. They will

real

ize that there is simply something that is giving them all kinds of problems. People often tell me about urinary problems. They have to urinate all the time, but it doesn't come out much. Almost as if they had a urinary tract infection. Sometimes people have a lot. of problems with pelvic pain that cause women to visit the gynecologist many times very prominent numbness and tingling they hear that a lot and people often end up going to see neurologists and worrying about multiple sclerosis and other problems rashes itchy skin that is really very irritating and people end up going to see dermatologists looking for some underlying problem and chemical sensitivity so they can't tolerate different things on their skin and that's just a short list actually people tell me everything kind of things.

On top of that, it really is a very wide range of problems that are extremely detrimental to people's lives. Well, is this kind of how big a problem it is? And it is a huge problem. I mean, it's a huge problem, so here's a lot of people have back pain, but obviously that's a short-lived thing, as well as neck pain, osteoarthritis that we see in a lot of people as they get older, and joints. They start to wear out and that's a big problem, but usually later in life, five million people. It is estimated from this national arthritis data working group that it has a high mileage in the country, that is, five million.

Actually, if you think about it, that's more than rheumatoid arthritis and lupus combined, as well as most of the other two, as I see, in fact, if most of these people. When we came to our clinic we wouldn't have time to do anything else, so it's a huge problem, but despite that you don't hear much about it, it's been a while since I read on the front page of the New York Times about Fuego

manageable

. You also heard a lot about cancer, so I can take Smith to that comment. You know I'm there in the room, but no one seems to recognize me and that's really how it is.

Manager, okay, so how do I diagnose the fire? Malchus, so people want to know all the time how this is diagnosed and people are always interested because there is no blood test, no EMG study, no procedure that can make it say that you have fibromyalgia and it is common for people to want that type confirmation. to my clinic asking if I really have rheumatoid arthritis. I had the blood test done and they feel like they can't understand it because of a bad job, but in reality the layoff diagnosed me with Malakai just like I diagnose any condition, it's almost always in what people tell me.

In addition to what I find in my physical exam, like I said, the hallmark of cultivating al-jihad is spreading pain, so that's the first thing I hear when people come to my clinic and talk about their pain, one of the first things What I want to know is where is her pain and people with knowledge of fire are going to end up, so I put this figure here pointing out the fact that this woman has pain in her shoulder, forearm and upper neck. and her upper back and her other shoulder and our lower back and her hip and that and that's pretty typical, in fact, these particular more central areas are pretty typical.

All that being said, people, if I'm eligible, can definitely have pain in their hands and their feet or anywhere further away, but widespread pain is definitely the norm, so that's the first characteristic and then the second characteristic that I already mentioned is that people have a lot of fatigue that is very disruptive in their lives, they have difficulty sleeping, so most of the time they tell me that at least most of the time they wake up feeling like they are not sleeping. good. They don't always tell me that they really can't sleep at night or that I feel like they're tossing and turning all night but they almost always tell me that when they wake up in the morning they don't feel like they've slept well and I'll go back to some of the details a little bit. and then finally, people often, as I mentioned before, complain about cognitive problems, difficulties thinking, difficulties concentrating, difficulties remembering things, so when you put those sort of two groups of things together, I'm usually quite concentrated, he will probably be the person of five.

Then I start asking about the other symptoms that I mentioned before, so I'll ask about problems without headaches or chest pains and things like that and often people will tell me that they've actually had tests done. for all those different problems from other specialties the specialist that comes by all the time yes, I went to the cardiologist they told me that they couldn't find anything in my heart and that is also useful for me because that assures me that there is actually no underlying problem. The problem is that this actually all goes back to fire management, so those are the key features in making the diagnosis for me.

Now there's another feature that people have probably heard about tender spots. There's been a lot of talk about sore spots, so where does that come from? The American College of Rheumatology developed this classification criteria for diagnosing fibromyalgia, so the American College of Rheumatology does this for many conditions. The reason they want to do this is that they want to get people into clinical trials where they can be pretty sure. that the patient really has that diagnosis, since it wouldn't be very good to study the effect of some new drug on a group of people who didn't actually have the disease you thought you were studying, so you've done this during rheumatoid arthritis and they did it for lupus and they did it for fire management.

Now I don't usually use the classification criteria to make any diagnosis, whether it's arthritis or lupus or whatever, but it's a useful guide and that's why they did this with tender points and So what they did was they identified 18 points on the body that They are sensitive. Now these 18 points are really sensitive in anyone. It's fun to play with my children. Still, these are just a tenor of places on the body with sensitive areas on them. body, but in people, a firefighter Joe, when you press them it causes a lot more discomfort than one would normally expect, so the people that I see often with Farm Alger I will press these points so as not to really see if they have 11 areas that They are particularly sensitive. but it helps me gauge if people are more sensitive to pain than I normally expect from most people, so these areas are slightly helpful and sometimes people if our mouths are extremely sensitive and, to say True, some people aren't particularly sensitive at all, but that doesn't necessarily steer me away from the diagnosis because, like I said, a lot of it goes back to these two characteristics, so the tender points aren't that important to me in making the diagnosis. , pay attention, okay, so that kind of is what I'm looking for in the diagnosis and then of course there's another key component to all of this which is making sure that someone doesn't have any other illnesses and that's important because certainly Other conditions can cause chronic widespread pain, fatigue, and even sleeping problems, so some of those different conditions include hypermobility syndrome, so people who are super flexible seem to struggle with a lot of widespread pain.

It can appear this way not typically, but it can be an autoimmune disease, lupus can definitely give a lot of these different types of symptoms, as well as neurological diseases like multiple sclerosis and Parkinson's, but that being said, you can usually find almost all of them. these conditions. something else is happening very often, a lot of things happen, whether it's blood tests or just talking to someone, that really gives clues, at least to me, that there is some underlying condition. It's rarely a big surprise to doctors when one of these conditions is actually a quarter. present, so it's not really a subtle art just to be able to identify someone with Malchus, a pose for someone with lupus, we, some of us with lupus, are going to show up with intense rashes, several swollen, swollen joints, things are clearly different than people in farm alger the other thing people always ask me about is infections, so all the time everyone is wondering: well, i feel really bad.

I wonder if I have an infection that we can cure with antibiotics and then I'll feel normal again so everyone always wonders that and the big infections that people always wonder about are things like HIV and EBV and then of course, one of the big ones that comes up all the time is Lyme disease, but that being said, like the other conditions, most of these things are easily distinguished. and above all, things like EBV and the flu are usually self-limiting, they go away, the symptoms go away after a while. EB v is the Epstein-Barr virus, so that brings me back to the fact that usually when I talk to someone and I'm identifying these things and these things are usually the ones that key me in and if someone really has a fire bad juh, while all other conditions generally there are many more computersin operation than just these two main components, okay, so the question Well, is what is causing the pain that you shoot around you, so I will come back to this figure a lot and what I am trying to describe here is a signaling circuit from pain.

I'm going to break it down into two components. so there is a peripheral component, the nerve that goes from the muscles or tendons and ligaments to the spinal cord and then there is a second nerve that carries these signals to the brain, either to the somatosensory cortex, if you want to be exact, two main types of connections , so the peripheral nerve and the central nerve go up, that's how pain signals are generated, so of course people started wondering where the pain is coming from. So they took a very methodical step-by-step approach and a One of the first things people started to look at is if there is a problem here, is there a problem in the muscles, tendons or ligaments somewhere that is causing all this pain?

Thinking about we're painting them, certainly one place where the pain comes from is the joints, so there's the hip joint or the spine and then of course it's also the bones themselves and then often right at the side of the bones. These bursa or verse structures that basically protect the bone and provide lubrication and many different studies have looked at joints and people with fibromyalgia and no one has been able to find any abnormalities in the joints. Now sometimes people, if I can, can. I also have osteoarthritis, but that doesn't mean osteoarthritis is causing fire mode, so people look at other structures and things, including muscles and tendons that connect muscles to bones, as well as nerves, and wonder if there is any problem there.

Is there information about tendonitis or is there nerve damage like diabetes does, but in all of these cases no one has been able to find any reproducible evidence that people with fibromyalgia have any damage to any of these structures, so it doesn't seem to be a problem? in the structures themselves, which made people wonder if there is damage, maybe if we think about the muscles where there is a lot of pain, maybe there is some metabolic problem, maybe people with fibromyalgia just something is different in the muscles where there is a metabolic problem that causes the muscles to not function quite well and that will cause pain, so there have been many studies that look at muscle metabolism and do biopsies that measure the production of metabolites and whatever, and no one has I have.

Reproducibly find any problems there, there have definitely been studies here or there that say yes, there is some problem, but when people have gone back and done things carefully over and over again, they haven't been able to show any problems that can be detected with the time. that doesn't seem to be the problem, okay, so if the problem is not here, then people started to wonder, well, maybe the problem is somewhere in this part, somewhere in the nerve connection, then the People started wondering, well, maybe there's something going on inside. the nervous system that is leaving people more sensitive to pain and the indications of that came from looking at the cerebrospinal fluid, so the fluid that is obtained from a lumbar puncture where it was observed in several studies that there appear to be differences in the levels of neurotransmitters that seem to be associated with pain, so there seem to be subtle differences there and that doesn't really explain where the pain is coming from, but it gave the feeling that something is happening at the level of the central nervous system that seems to be leading people to have more sensitivity to pain, so people started looking at how people with fibromyalgia experience pain, so researchers started looking at how they experience me and what they found is that, in fact, people with some in the arms they are more sensitive. to all kinds of different paints, whether it's heat or cold or pressure, and that's illustrated in this figure here, try to avoid showing you too many slides of data, it's a little dry, but what this slide is is just having a researcher you press with a very fixed amount of pressure on someone in the same place on their body and they do this live for different people and they see when they press it when they put two pounds per square inch if it causes pain so they just ask the person who did it ago is that painful and they found in this group of people with fibromyalgia that it was about a pound and a half per square inch or they forget what the exact units were that caused pain, whereas normal people or people without you.

Knowing the chronic pain issues that we could, we actually had much higher levels of pressure that would actually cause pain and then they did another important check, which was looking at people with chronic pain, but in kind of a very focused area so that people with chronic pain low back pain and these people are actually more like people without pain, so there really seems to be something different about people with knowledge of fire about how they feel pain. Now the problem with this study is that it is still very subjective. You're asking people what they feel and that's not as accurate as you'd like to be, so we try to take people off the topic, people's subjectivity out of this experiment, how many researchers have done it in a different way. and there's It's going to be a little complicated, but what the researchers used is this type of reflex, so I think everyone has had the experience of touching something that caused them acute pain and before they knew it, they pulled their hand away or the foot.

That is a normal pain reflex, which actually occurs faster than the signals can reach your brain, so your brain is not involved in that at all, so you made use of this reflex, so what What they're going to do is We're going to apply a stimulation here and then we're going to let it circulate through the neurons in the spinal cord there, the dorsal horn and then we're going to go back to the muscle and we're going to measure the contractions and the way they're going to do that is something called an EMG, so what the neural eye is a neurological study of the nerves or nerville that is performed in which an electrical stimulus is applied and then, with a needle stuck in the muscle, you can feel the contraction of the needle, so if you apply enough stimulus here, the spinal cord will register the pain. and then the muscle contracts and you can measure that, so what they did was add increasing amounts of pain until finally the muscle contracts by increasing amounts of electrical current until the muscle finally contracts and they did it with a lot of people and the difference was not It's huge but it's significant so what they're showing here is that people with fireman Joe had contractions at lower levels of current than people without fireman juh and to me that's very important because what really shows is that people of farm al jarreau's logical level without even asking about it, in reality, the way the spinal cord feels pain is more sensitive than that of people without a fire manager, so the point is that you really have the problem, it really seems to be here at the level of the The spinal cord and those fibers feel pain that makes sense, and what has since been called is a central sensitization to pain of the central nervous system or, of another way, I mean, it's a pain sensitization process, so that seems to be the phenomenon in farm algin and this doesn't just apply to pain from the musculoskeletal areas or what people perceive as coming from the musculoskeletal areas, but In fact, this happens at the level of the spinal cord and the central nervous system, in fact, people are more sensitive to pain signals that they perceive coming from anywhere, whether it is the intestine, presenting with irritable bowel syndrome or of the bladder, sometimes there is a diagnosis of interstitial cystitis or headaches or a disorder of the temporomandibular joint of the jaw, so all these things are phenomena that can be Phenomenon particularly the people of Malaga have a greater sensitivity to pain and in fact there are many people without fire in Malaga, so without the general pain part, but they have problems with fatigue and lack of sleep and often they have problems with pain coming from other places, so this In fact , this phenomenon of central pain sensitization seems to apply not only to the Malaga fire, but also to people with all kinds of different conditions in which it is difficult to find any underlying disorder, so not only five million people affected by a fight In the United States they have a fire in Malaga. but, in fact, a large number of people have problems with these other different types of conditions and that can actually mean that the same type of process is happening there and that it actually applies to many more people, so, in fact , they are often in the room. it's actually hell, it's way bigger than just the 5 million people with mallinger fire ok so what is causing this?

You know, what is that? Why do people get this? How do they end up with this problem? and we really don't have a very good or satisfactory answer, but we do have some clues, so from a variety of genetic studies done over the last 10 years it has become increasingly clear that there is a genetic predisposition or a genetic vulnerability , so you can actually find variations and genes or single nucleotide polymorphisms that actually predispose people to pain, and in fact, some of these mutations really aren't always hereditary, but they can be hereditary, so they really There seems to be a genetic predisposition, so the second thing is that it is not uncommon.

I have people tell me about farm algae developing after they have had some kind of traumatic experience, it's not always like that and it's not, and sometimes this happens after they develop our bad juh, but then things get a lot worse , but it's very common for people to tell me about some type of traumatic experience, so some of the things I've heard are things like a pretty serious car accident. In fact, there has been data suggesting that, in fact, people after a serious car accident. In fact, we're more likely to develop our mojo in car accidents.

Other things, serious infections and other medical conditions that cause admission to hospitals and, in particular, intensive care units. previous Lyme disease, so the truth is that people often after developing Lyme disease we don't see it much here, but certainly on the east coast people feel terrible because they have Lyme disease, they feel horrible and then the symptoms persist and persist and persist for most people recover from those symptoms, but it may take a while, but for some people they seem to continue and develop Malaga fire, we now know that the bacteria is long gone, we know, but people continue to have symptoms and again that kind of pointing out the fact that some kind of physically traumatic event seems to predispose to the development of our Belgium, okay then, but it's not just a physical trauma, it's actually an emotional trauma as well. which apparently can be just as effective in precipitating the fire and this really runs the gamut and I feel like people often don't tell me about this, but I also have a census.

It's incredibly common. One of the things people often talk to me about is the loss of a loved one, all the time I hear about people. whether developing Malaga fire or having much worse symptoms after having lost a parent or even more traumatic is losing a child, but in addition to that type of loss it is not rare, well, one says it is not rare, but sometimes Every now and then I hear about people with a more distant relationship. history of something much more traumatic, particularly sexually traumatic people, are often reluctant. I plan to tell doctors about that, so I don't think I don't care as often, but I have a feeling that it's actually a big problem that exists and somehow that prior trauma, whether it's violence or sexual trauma, can lead to to the development of fibromyalgia, so those seem to be some of the things that trigger this, but like I said, it's really not a complete list and doesn't give us a clear picture. guide to why people actually develop male fire, but it gives us some clues, is it important for fibromyalgia to be properly diagnosed?

The answer is obviously yes, so I think you know from a more altruistic or social sense, it's important because if the fire is bad 'chik is not diagnosed, people actually end up racking up a lot of doctor visits on a lot of tests, so here is a study done by a group where they actually estimated the resource expenditure on people who were diagnosed with fibromyalgia versus people who are not and what they did from their modeling is what they learned from their modeling is that people who don't are not diagnosed with fibromyalgia the expenses andthe number of tests increase and increase and the doctor visits and everything else related to medical care compared to people who are diagnosed with fibromyalgia, things tend to stabilize, which emphasizes that when receiving the diagnosis of fibromyalgia , worn out people end up spending less time going to the cardiologist for that chest pain and going to the urologist for that discomfort. when they pee and go to the neurologist for number one um this and tingling now obviously if you've fired the manager well I mean I don't really care what the impact on society is I mainly just want to feel better and I want to know what is going on with these things, but I think it's important to also remember that if you're a doctor, you're most likely going to have a test done, and if you go to enough doctors, you might end up with some test that's going to be abnormal that will still require more tests and you might even end up with unnecessary procedures from time to time.

I think people actually have things like their gallbladder removed because of chronic abdominal pain where they don't. It doesn't solve any problems at all, in fact after surgery you may even feel worse so I really stress to people that it's important to be careful when doing a lot of tests because it can actually lead to a lot of unnecessary things so I think It's really important for people to be diagnosed with fibromyalgia. Okay, well, what you know people said back then, when I asked. Well, what's going to happen to me? Will I feel better one day?

So I posted this slide. This is a Fred Wolf Scroop slide. in Kansas and I made it optimistic that people's symptoms seem to decrease over time in this case on a 12 year scale now the slides are a little unfair now this is a scale from 0 to 31 and I'm showing you that the average score decreased from 23 to 17, but really the scale should start at 0, so what this points out is that most people 12 years later still have a lot of symptoms, maybe you know that there is a 25 percent improvement during that time frame. Another study was a little more optimistic in saying that people understood that a reasonable percentage of people are actually five years later we are no longer diagnosed or firefighters, but I think the jury is still out on that, overall my experience is that people's symptoms seem to increase and People seem to have good months and bad months, people even seem to have good years and bad years, but it's not clear to me if this will ever go away, that being said, although it will never go away. what will go away, I think there are definitely things that people can do that will help them manage their symptoms and make them more functional and do more things that they want to do to get treatment and what I really want to emphasize and this part of the talk talks about treatment. is that there won't be any treatment that works very well, so people try medications and people try effects that affect the mind and people try interventions that affect the body and no intervention has been shown to be really very effective, but that's what they say.

When studies have taken a multidisciplinary approach, you start to see a greater difference in people's symptoms, so it is very important that people understand from this talk that there will be nothing they need to do; In reality, it is a much more comprehensive approach. approach well, so why don't we start with medicine, since it's the easiest thing to talk about. So let's go back to our model here, so there are a couple of different places that we can intervene with medicine as we think about this system, so that there is one place where we can intervene is to break down here in the dorsal horn and that is to affect the levels of North and Ephraim so that norepinephrine learns the neurotransmitters that are considered one of the fight or flight neurotransmitters the neurotransmitters that allow you to flee or fight against the line that is about to devour you and, obviously, in fight or flight It's important not to worry so much about pain when you're trying to survive, so the approach has been taken to try to increase norepinephrine levels, which will then decrease pain levels and there are a number of different medications that do that. , so a class of drugs is called tricyclics in its essence.

Now people, every time I start taking something like elavil, people say well, why am I not depressed. I will need a present ether and what I want. What is emphasized here is that most of these medications are antidepressants, but they are generally prescribed at lower doses than those prescribed for depression, with the goal of trying to increase norepinephrine levels to dull the pain and also other side of the depression. Another beneficial effect of all of these medications is that they often allow people to sleep a little more soundly. We'll come back to the importance of that, so tricyclic antidepressants, as well as this group of medications called dual reuptake inhibitors and dual reuptake inhibitors, meaning serotonin and norepinephrine, so now you're trying to increase norepinephrine levels, as always. , with medications there are always side effects and this norepinephrine tends to dry things out, which is why people complain a lot about dry eyes and dry mouth when they take these medications, but they are reasonably effective in a limited number of people and it doesn't fit me It's not clear how long that effect lasts, so studies say that probably about half of people respond to these medications, maybe a little more, and studies say that people probably have a 25% improvement in their pain. , so it's not a huge improvement, but it's a solid improvement and when you're in that much pain, it's going to take 25%, so they definitely play a role, it's also like I said.

It's not clear to me how long they work, it's not uncommon for me to ask someone a year later if they think cymbalta is working and people will say I really don't know, so I think these medications are helpful for pain relief. control initially, but it's not necessarily something that's going to work for a long time, not necessarily. I think we still need to learn more about that, obviously, pharmaceutical companies are not going to rush into these long-term studies, most studies. They are usually fine for half a year at most, so the next group of medications I want to talk about are those that have an effect at this level, so these are the nerves that release modals that then stimulate the dorsal horn and What these medications are going to do is block the release of neurotransmitters here by these nerves to help block the release of neurotransmitters so that you don't have signals coming from the periphery, so these medications are the ones you see on TV all the time. time. gabapentin is the oldest letter, in fact it is gabapentin, but it is just a different form, but in both cases they can be useful, people usually tell me that they are more useful for paints that burn more, so when people have tingling, burning-like pain coming from anywhere in the body, these medications tend to be more helpful, but on the other hand, people often tell me that these medications make them very sleepy or confused and most of the time I find that people You don't like them, so I'm not particularly fond of these medications, except in people who really complain about that burning type pain.

Well, let's review some of the data that we have on medications, so we tried to talk about tricyclic antidepressants, one of which is amitriptyline, although the other group. They are dual reuptake inhibitors, so they will increase norepinephrine levels and decrease pain, help people sleep a little better. The second group is gabapentin, pregabalin and then a third or a third through medications, if you will, that helps the bending of the tree farm algae. or cyclobenzaprine, which is a muscle relaxant and actually seems to be helpful in some people, although truth be told, I think a lot of that is because it actually has some effects of elavil, so it actually mimics these actions.

I think it does less to relax. muscles and more centrally and then another drug that exists that has been shown to be somewhat effective is a drug called tramadol, it's kind of a light codeine, it's a partial opiate agonist, so it doesn't work like something like that. like vicodin or oxycontin, but it has effects that appear to be at least somewhat helpful in people who grow allergens. That said, it can cause a fair amount of constipation, so it doesn't always go so well with other things, which is why the various endings are medications. I think we are most familiar with over the counter Advil Motrin Aleve, which has been studied extensively as have others and no one has been able to show that they are effective or for a sustained period of time for people with fibromyalgia.

That being said, I sometimes recommend that for people who have pain in other areas of the body or who have a specific pain that they are trying to treat, for example, someone who has a lot of arthritis in their neck, might benefit. of NSAIDs because having less pain coming from neck arthritis could actually help improve your overall pain, so sometimes there is a role for things like motrin advil one in treating things like that, prednisone has been looked at Look closely now, it's not uncommon for people to come to see me and say whoa I was sure I was diagnosed with lupus and I really think I have that because when my doctor treated me with prednisone I felt much better but the truth is that you can give anyone a dose high prednisone for anything, in fact, the effects of steroids are very powerful on the brain and can make people feel better, but that effect tends to be short-lived and then of course all the symptoms occur. other side effects of prednisone and that type.

Doses of 20 milligrams a day or more are extensive and can be serious and can ultimately lead people to having a lot more problems than they start with, which is why I definitely steer people away from benzodiazepines prednisone , so the things that help people sleep are not big. Soy fan can often be helpful at first people may say that I sleep much better when I have my ambien, which is a semibenzodiazepine, but in general my experience is that over time people find that they can't get a good night's sleep. they can't sleep at all without taking their ativa or their ambien, in fact they end up back in the same boat of not sleeping well and relying on these medications to sleep, so they get higher eyes so no surveys are recommended , there are other medications to help sleep, like Tradone and some others, and there is varying experience on how effective they are and finally opioids, so I definitely know some rheumatologists who prescribe opioids for fibromyalgia.

I'm not a fan of them. If they haven't been shown to be effective or sustained time at the same dose, similar to my experience with benzo days, it means I think what happens is some people start taking opioids, so things like vicodin or oxycontin It's like they definitely relieve the pain. They have pain relief, but the problem is that the pain relief effect tends to decrease over time and then people need a higher dose to get the same analgesic effect and then people tend to increase higher and higher doses and That tends to eventually have a lot of other effects on your body, including making people feel very lightheaded and high, so I'm not a big fan of treating people with narcotics.

Some rheumatologists say that's the only thing that will make a difference for some people. your pain is so intense and I understand that point of view, but I think in the long run that's a good thing, it will ultimately work against people, so if they need a narcotic, I always recommend that it be for a limited period of time and that people work really hard to try to quit, okay, so that's the drugs, so in my next cut, my next comic, ask your doctor if taking a pill to solve all your problems is right for you. you and you know, I think we all feel like this, sometimes, like we really know we have some problem and we just wanted to go away and we want to be calm, you just know, you take a pill and you chase the glass of water, you feel bad, but, for Of course, unfortunately that's not often the case and in fact when I ask most people if they choose to take pills or not, most people say no, I don't really want to take pills, in fact if they are given the choice between having to take pills or other strategies, people often use.

I want to move on to the other strategies now, that's not always the case when it's really bad pain, but when I think about it in a more global sense, that's the option usual thing that people want, so that brings me to the next topic, which is the body. And what things can people with five myalgias do for their body? So that brings me to exercise, which has been proven time and time againin multiple studies that it makes people feel better, sleep better, and function better, and this has been shown in many different studies. with a lot of different interventions, so the different things that I tend to talk to people about are like walking, using an elliptical or a stationary bike, swimming, great swimming is great, whether it's swimming itself or water aerobics , stretching and key tai chi or Qigong, so a little bit about each of these, so it's been proven time and time again that walking is the intervention that people are most likely to incorporate into their lives and keep up, so now I'm a fan of walking, when I say walking, I'm not talking about you.

I know what they ask people, well, what about you know, walking around my house, that doesn't count now, that doesn't count, so this is exercise, so what that means is that you're identifying a period of time when are you going? Go out and do something good for your body, if possible, that means you will go out and exercise at a pace where your heart rate will increase a little. Ideally, some people will even sweat a little now. when they're raw, that could mean literally five or 10 minutes, literally, that's what they can do and then they just wipe it off, but what we're looking for here is 30 to 60 minutes somewhere in there and it could take Honestly, it can take It takes three to six months to get to that level, people have to develop it very slowly, but that's what you're looking for and walking can be very difficult for some people, especially if they have lower back problems or a lot of pain and the sides of the hips or a lot of arthritis in the knees, all those different things can make walking a lot more challenging, so it's important to do something else, so cycling can sometimes be very good for some people.

I think these elliptical machines are a little better because you don't have to bend your neck back which can be very bothersome to some people's necks and they seem to be very gentle on the rest of the body, as I mentioned water aerobics and swimming are fantastic because of the zero gravity nature of water and I'm a big fan of those things now of course, one problem is that except for me, with minor exceptions, it's rare that people can do water aerobics or swim every day, but if you can incorporate it into doing it at least a few days a week that's fantastic or even a couple of times a week and the Arthritis Foundation has a lot of different programs for this type of thing in the city.

As I mentioned, people with fibromyalgia have a lot of stiffness problems, people are very very stiff and having a stretching program to do every morning seems very important to me and it is something that I think is important to do every morning and ideally. even twice a day and I ask people to work with a physical therapist to develop a comprehensive stretching program for them. When working with him, there are physical therapists for some, it is important to find a physical therapist who is familiar with fire. Djem man. People with fire. Maui. Finding a sports therapist tends to come back to me saying, "Oh my God, he put me in these positions that I've never felt in my life," so it's important that you find someone who is familiar with fibromyalgia and who is familiar with the creating a very gentle program that people can add to or intensify over time to make it more effective, but it won't make them feel much worse right away, aside from generalized stretching, it's not uncommon for me to often see people with farm alger with extremely tight muscle groups and specific areas. related to some kind of problem with osteoarthritis or something, so I often refer people to the physical therapist not only to develop a generalized stretching program, but also to focus on specific problem areas, which is why I see all the time someone with tight muscles in their neck from holding themselves like that all the time or people who have very tight lower back muscles and very tight buttock muscles and a lot of pain in the sides of their legs and have extremely tight muscles there and then. physiotherapist will create a complete program for that, so I find that very useful, in addition to this type of aerobic exercise and finally Tai Chi or Qi Gong.

Recently, there was a very good study from Tufts, my alma mater, looking at the impact of Tai Chi on people with fire myalgia that was published in the very prestigious New England Journal of Medicine because it was very effective, so I'm a big fan for it. those of you who are not familiar with Tai Chi, it is basically a martial art in which people are doing different types of postures that have a combination of isometric elements as well as a certain degree of stretching and I will incorporate into all of that there is also a meditative component and that grouping of components seems to be very effective for Firebaugh's management work, so I definitely recommend that people try it, so the last point I want to make is that when you have diffuse pain it is very difficult to do these things, it's really very difficult to do these things and all the time. people come back and tell me actually when they did all these things right I did it I did it sideways I'm going to go and I'm going to walk 15 minutes a day and they say and they come back and Let's say I did that for three days and that was it.

I couldn't move for a week, so what I want to emphasize is that it's important for people to start very gradually and in a very regulated way and, in fact, I encourage people to take out a calendar and say what they're going to do. do every day, starting with something ridiculously easy and building up very, very gradually and knowing that when you start on the 15th, I didn't even realize I was ten. I didn't even focus on this tax day, wait, maybe you want to start a fifty, start before that, um, you have to admit that you know that when the 18th rolls around, you're probably going to feel worse when you first get going, but still So what you wrote is that no, I'm going to continue with this.

I'm going to do it. It says on the calendar. I'll do ten minutes. I'm going to continue with this and continue with yes. Your plan is really important, stick with your plan, so get out the calendar and mark what you are going to do. Here are some tips and I have this in your brochure and it is completely illegible in your brochure so if you want these tips you should send me. an email, send me an email to andrew gross at UCSF edu, so now everyone on the internet will have it too, but anyway you can also get it from the UCSF website and say: Hi, can I have the slides in a format More legible?

I'll send them to you in a larger format, but this is why these are helpful tips that I found to help you get started and keep going, so I talked about exercise, diet, healthy eating, what's up with that? Well, everyone always asks me what I should do. I eat what I do and the truth is that there is no convincing data that there is a diet, a food or a nutrient that can really reduce pain, so we don't have any data on that and people have analyzed it in a way Variety of different things from vegan diets and live food diets and all that, and there's nothing compelling, but that being said, we know that people who have a higher body mass index, people who are obese, are more likely to have farm algina and we know that people are beasts. with Firebaugh they often have a reduction in symptoms when they lose significant amounts of weight;

In fact, there's even a study that looked at bariatric surgery where people lost large amounts of weight and actually had a significant improvement in their symptoms, so what that tells me is that while there may not be any foods to really reduce people's pain, I think eating healthy in addition to exercising is extremely important to basically take care of your body, prevent weight gain, and actually facilitate some weight loss, so like I always said, Ask me what I should eat and I say, Well, it's really up to you, but I think whatever you do you should try to find some kind of healthy diet that really works well for you and there are a million different kinds of diet books.

There could be different suggestions, but a really good resource for that is actually the US government, which is why the USDA Department of Agriculture published these Dietary Guidelines for Americans in 2010. This is different from the old pyramid because it really emphasizes a complete combination of foods, but in limited quantities, so they emphasize that you want to limit your total caloric intake, one of the very important and difficult things to do in American society, where you get a huge plate like that to remember, no, no. don't eat it all so in combination with physical activity now for those of you who really don't want to so what else can I do for the diet?

One thing I do point out is that the sponsor of this talk is an Osher Center. for Integrative Medicine here at UCSF and they have a different life in their group. We like to think a lot about diets and work with people to modify their diet to something that works well for you. Well, that's diet, so the third part is. get a good night's sleep and obviously, since I want at least one of the things I've mentioned, the onset is one of the hallmarks of fire mouths that people feel when they wake up, I just don't feel like they've had a good night's sleep. evening.

Sleep One of the interesting studies that came out of Stanford in the 1970s was a study done by this guy, while Toski, who looked, took a group of undergraduate and graduate students and hooked them up to an EEG and measured their waves. of sleep and every night. when they fell on the stage to sleep, so that's deep, deep, deep, relaxing sleep, not the rapid eye movement part, but the deeper, relaxing sleep, and he measured me, that's where people come in in the Delta wave dream and every time they fell into the Delta wave. while they were sleeping, he would play loud noises to get them out of that stage because sleeping usually wasn't enough to wake them up, so if you ask people if you woke up last night, they would say well, I don't know, maybe once or twice I heard something, but no, I don't think so, I think I slept well, but after doing that for about three days, people reported that they felt like they had fire mal'chik, they had paint all over their body, they say it, headache , said Domino, upset.

There is a disaster after only three days. The other interesting thing about that study is that in that group there were three people who were athletes, three people who were long-distance runners, and they couldn't wake those three up. get him out of stage four sleep, they just went through whatever we play and yeah, I think that's great and it reminds me that exercise is important not only to take care of your body, but it's actually helpful to take care of your mind and getting a good night's sleep, so lack of sleep is associated with the development of widespread pain.

People with fire mal'chik commonly have sleep disturbances and it is important to try to return to restful sleep, which brings me to my next page of advice, which You can email me again or this is already on the way and these are just sleep hygiene tips and one of the most important things is to just have a regular bedtime and even more importantly have a regular wake up time so you should be waking up at the same time every day now obviously there are limits to what people can do and we all have busy schedules just to do different things in our lives, that doesn't always allow for it, for me it's my three year old son who decides to come. at different times but as much as possible try to wake up at the same time and sleep through the night is incredibly important okay that's Pharma so that's just the sleep part and finally I have to say I'm a doctor .

I have to say don't smoke and in fact there is good data that smoking makes paint worse. Now the little caveat is that when you quit smoking you tend to gain weight and then people tend to have more pain, but that's true again. that's something

manageable

in the long run, it will be a good thing to quit smoking, so I highly recommend people not to smoke, so some advice make smart decisions, don't smoke, eat well, stay balanced. important, so again with that schedule that people say, okay, this is what I'm going to do this week and I'm going to stick with it and I'm not going to rock the boat and try to go super enthusiast. and I'm not going back.

I am going to do things in a very regular way and maintain a healthy lifestyle. Okay, so the last part is the mind. This is often dismissed partly because people tend to consult doctors who are less trained in this area and partly because of the fire Browns stigma of it being all in people's heads, it's all in my mind, it's a invention. Not really, I mean, you're not really in pain, it's just all in your head and So the last thing people want to do is talk to a therapist.about something that might be happening, but in fact this has been shown to be incredibly important, so one of the things that has been resolved over time is that there is actually a vicious cycle or a pain. cycle that is present in people with any type of chronic pain and the phenomenon is that in people with chronic pain it leads to a lot of negative thoughts, so the anxiety, of course, about the pain, you know because you are tired of being and tired . from having trouble sleeping and then P and not coping well with the pain and all of this seems to lead to even more pain so it becomes kind of an intertwined disaster.

There's actually some pretty good data behind this, so on a neuroscience level and this is pretty cool, so there's actually a whole system here that actually modulates pain, so not only does this nerve come in, but it also there is an option here where some signals, instead of increasing the pain, can reduce it, dr. Henry was talking about this last week about how when you hit yourself there is a tendency to rub the spot that you hit and that rubbing actually stimulates different fibers that are actually going to inhibit pain signals, so that's the idea that it is really coming.

From the periphery there are ways to stimulate nerves that actually give inhibitory signals to modulate pain, so there is a lot of complexity there, but even adding to that level of complexity, there are actually descending fibers, so there are fibers that descend of the brain that can modulate this and can do so. Can they increase it to block the pain or can they eliminate it to make the pain worse? And one of the things that has been appreciated is that negative thinking, so to speak, depression, anxiety or catastrophizing, really, oh my gosh, it's the veins. It's been shown that the worst thing in the world that can actually lead to pain getting worse and there's very strong neuroscience behind that, so this is clearly a problem that actually makes pain worse, so I like this slide and I like this quote: What would life be like if you could influence the way you think and feel, what would life be like if you had so much control that you could, you could influence the way you feel and that brings me to this kind of slide peaceful looking and things you can actually do.

Doing that without taking drugs, that brings me to cognitive behavioral therapy, so cognitive behavioral therapy has been shown to be very effective in many different studies and the rationale for it is that there is an educational component to understanding pain or where there is the pain. Coming from goal setting, recognize that, well, you're probably not going to go out and run a marathon, but there are certain things that you should be able to look forward to so that you can relax and then, like I was just referring to, identifying dysfunctional. thinking dysfunctional thought patterns and techniques to counter negative automatic thoughts so basically ways to challenge you know when you're in this is horrible mode.

I've never felt so bad in my life ways to challenge that thinking now obviously that's not normal What people should do, you know, when you're in survival mode, just trying to get through the pain, you're not going to be thinking straight. How can I challenge these negative thoughts? And that's really where cognitive behavioral therapy comes in because, honestly, you need training in the sense that you need someone to teach you how to be able to do it. and do it in an effective way where you can actually control the pain. Like I said, there are a lot of different studies that look at that and say goodbye to Malaga that show that people's function improves after a six- or eight-week course of cognitive-behavioral. therapy and in fact, even more interesting, there is neuroscience that even supports it, so going back to this kind of thing, remember the experiment where we are actually putting a stimulus and then we measure the sensitivity in the muscle contraction without going through the muscle contraction, so By measuring how sensitive people are to pain, what was actually shown is that after six weeks of cognitive behavioral therapy, people's sensitivity to the stimulus decreased, which is pretty good, so that after six weeks of simply talking to someone, people's pain levels actually increased. sensitive to pain and not only was there less sensitivity after six weeks, but six weeks after having nothing afterwards, people continue to have that effect, so again I thought that was great, just talking to someone you can decrease your sensitivity . pain well talking to someone to learn techniques so they are young so learning to challenge negative thinking helps improve this inhibitory response to decrease pain levels okay so the last thing I want to talk about is that is working. with the people in their lives and their relationships, so it's clear that farmed seaweed is extremely hard on couples.

I see that it is extremely difficult all the time in couples, not only in couples, but of course in the entire social structure of people, where people feel that they have everything. this pain, but no one else can see it, so they end up feeling very isolated and this was studied very well by this group who looked at relationships and whether they are positive, whether they are beneficial or harmful, and what they found is that It's not surprising that is divided into two groups, so when relationships between people create a level of understanding, support and recognition of their pain, this tends to be very helpful, whereas in relationships where people's pain is dismissed and You can dismiss it in one of two ways. it may be from denying it, that's obvious, well, I don't see your streak, so you know, cheer up, but equally problematic is this kind of thing of being condescending, well, let me take care of you, you don't have to do that and you.

You know, they're doing too much, that's problematic too, so what I really encourage people when I see them is that it's important for them, not just for them, to learn about Farm Alger, but also for the people in their lives, learn about Farm Alger. Its effects and what they can do together and it really hasn't been studied that well, but I get the sense over and over again that that's incredibly important for people to feel like the people in their lives are helping them manage and be. further. proactive in managing them and helping them feel better, so I summarized it, so I summarized the medications and I summarized other things.

Moderate evidence of efficacy. Cognitive-behavioral therapy. Aerobic exercise education. Group therapy. Strength training and acupuncture have been looked at a lot, and there are limitations. Evidence I think the main thing we've learned about acupuncture is that it's not so much about where the acupuncturist places the needles that it actually seems to be less important, regardless of where the paint is, whatever the source of the pain, whether it's five managers or osteoarthritis, and more importantly. is that you have a very good acupuncturist whose very presence is calming and supportive, so going and seeing an acupuncturist that you are not helping, that you are not comfortable with, is probably not a good strategy, biofeedback seems to have some role and that influences cognitive-behavioral therapy.

The Osher Center does a lot in this direction with something called mindfulness, very weak evidence working with chiropractors, massage therapy, electrotherapy, ultrasound and then something that was more popular ten or twenty years ago, where these trigger point injections injected steroids into areas that were particularly painful and in fact there is excellent evidence that if that works, it doesn't matter what you inject, so the old studies went back and looked at steroid injection and usually you started with red plus lidocaine and so on. they just know the anesthetic medicine of novocaine and they found that there was no difference if you just took novocaine alone or more historical novocaine, so people, well, what about the novocaine in the steroid versus just salt water and it worked?

Okay and then they said, Well, how about we don't inject anything at all? We just put the needle in and blow it out and that actually works as well as anything else, so, you know, that keeps us coming back. in that direction so I'm not a big fan of that stuff okay so in summary major fire represents a core sensitization condition to paint that people are more sensitive to pain and that's very real there is a neuroscience behind it. Therefore, systemic disease must be excluded, but I also put that into emphasis that it is usually quite obvious to doctors when there is an obvious disease when there is a disease present that is actually masquerading as bad Djem, it is usually not a secret fire, bad Jay.

Diagnosing and limiting unnecessary medical use and limiting subjecting people to unnecessary things and procedures is important, and fire mileage is definitely manageable, but it requires a very conservative effort with multiple different approaches and it's rare that anyone really can. to get away with just taking a pill every day and feeling radically better, that would be great, it's rarely the case, so it's real, now it's manageable, you know, by that I just want to say it, everyone can feel like The Incredibles and I want Cue some help from my friends, so Bev Leah is here at the Langley Porter Institute.

She's a therapist and she really specializes in a lot of things that we've learned about cognitive behavioral therapy. David Clayman runs the sleep center. here at UCSF and my wife is always a doctor, she really gives me very helpful feedback, so with that and then additional things that you can't read in your brochure, but this is a journal article and like I said, if you email me electronic, I can give you You have everything, but this provides a lot of resources for people with fibromyalgia, both books and video tapes and websites, and one last add I want to do is for the Arthritis Foundation, which is here in Northern California, San Francisco, and manages many things. from different programs for people with fibromyalgia, they are extremely helpful and I highly recommend that people also check them out at the Northern California Chapter of the Arthritis Foundation, so thank you, okay, so I imagine we'll have a question: okay, Yes mom. "Yes, it is seeing boys, it is unusual in prepubescent children, but from the age of 16 it is definitely seen frequently in particularly young girls, what do you mean?

No, it is not definitely not in our immune disease, so that you go back to those Questions that you have on the previous slides about looking at the joints, the muscles and the tendons and there doesn't seem to be any inflammation, there's no damage, there's no information, so it's definitely not an autoimmune disease, in terms of and I think about what I want. To emphasize, there doesn't seem to be any structure that is breaking down the body, including the nerves, which is actually all intact, but the problem is the way the central nervous system picks up pain signals, which is fundamentally the problem, so the central nervous system actually reads things in a way where it is more sensitive, it's almost like if you change the thermostat a little bit, so that seems to be the problem and there seem to be these factors that lead to it, but exactly how we do it.

I don't know what kind of brain scans you can see of emotional pain and physical pain appearing in the same place. Yes, is it job related? So there are studies that look at things like PET scans and MRIs and how the brain works. responds to different types of trauma and I think studies have looked at people with physical trauma and people have looked at emotional trauma, so a lot of effort goes into trying to correlate what they learn in these studies about physical or emotional trauma. with what you see. in people with different types of conditions, including jaw fire or chronic fatigue and things like that, and trying to extrapolate well what we can learn from that and my answer is that unfortunately I don't know enough about that research to give you a whole decent answer on that. , yes, that would be a better topic for some of the neuroscientists, yes, yes, so what do I do, yes, what do I do with the fact that that emotional or physical trauma can trigger it?

I know it's a tough question, the answer I know you know, in a sense, people feeling pain, whether it's physical or emotional, has very real effects on people and I think we've all seen friends and family go through that. kind of thing, so maybe in some ways it's not that different, yeah, yeah, so the question is is there a relationship between mental illness and fibromyalgia, so not really, for the most part, so some warnings so that things like schizophrenia do not trigger Melcher's depression. In reality, he is not predisposed to dismiss men's work. Now many people with fibromyalgia have depression, but it seems to be a more normal response to feel pain all the time.

The only thing that seems to predispose you to cultivating algae is anxiety disorders, sopeople with anxiety disorders. seems to be a more likely result of chronic pain and chronic fatigue, yes sir, yes, so what kind of pain am I talking about? Get a different answer for each person with fibromyalgia. It's completely different and it's even more different for men than it is for women. It tends to be much more focal and much more intense, but it can be anything, so for some people it is a burning pain. for some people it's a stabbing pain, for others it's just a suppressing pain, it really is incredibly variable, so the noise goes way beyond the noise, yes, that's right, so you know.

I think one of the things to emphasize about Farm Algin is that it will have some kind of functional impact, so I think most people, a farm manager, will tell me that in one way or another it is affecting the way that work, that they are less likely to be as active and do these things with their friends now that It's like with all medical conditions, there's a spectrum, some people are really bad, some not so better and it's not necessarily more likely that the Symptoms get worse and worse unless certain things happen, so, for example, you know you're pretty sore. but it's not that bad, but suddenly your mom dies and then it's not unusual for people to show up saying I'm much worse or the person who kicks her out again and spends a month in her bed and stops exercising and doing other things . things that know that we are good for the body and that are doing much worse.

I hear that all the time, so there are certain things that can alert you and make things worse, but in terms of quality. of pain, anything goes, yeah, so the question is to go back to some of those last few slides about how to have positive relationships, be supportive or negative relationships that we deny or condescend to and how to get people to be more supportive and less condescending or denying, you know, and I don't have a good answer for that because, of course, that's the challenge of signing up people and some idea, but nevertheless, that's the idea of ​​pointing and maybe, if it works, you can say that the Dr.

Gross said that, um, that. It's more helpful to me and me if you support us more and one of the things that's later helpful is if you find something that you've read or seen that helps people better understand what you're going through. tell them how to give them a better idea or just how or if they're willing to do it and sometimes they are and sometimes just talk to them about what it's like and how you've been limited and how it's affected your life so it's definitely a challenging thing but it's something really challenging, but it seems to be important, yeah, so I mentioned the Arthritis Foundation, so there's no direct relationship to arthritis, so again, for Fire Millage itself, you know there's no joint damage.

He said that if you have a lot of osteoarthritis maybe your neck or your back, your knees or that is a constant source of pain that can intensify pain sensitivity and all the symptoms of fibromyalgia. How did the Arthritis Foundation end up with Farm Al-Jamal? a rheumatic disease in the sense that many sensations from our mouths, all in the muscles, joints and periphery, and which ultimately ended up in the world of Rheumatology, ended up in the world of the Arthritis Foundation, but having said that, the The truth is in a sense, this doesn't really belong to anyone, any medical specialty, because it affects many different parts of the body, yes, there are many different support groups and a couple of things about support groups, etc.

One way The way to do that is through cognitive behavioral therapy groups and that's actually done here through the Arthritis Foundation. I'm sorry, through the Langley Porter Institute or the department of psychiatry at UCSF, they have a support group, a cognitive behavioral therapy group, I should say for people with chronic medical conditions or depression that includes pharma algin, so that's one way to join a group that won't necessarily just get you fired. Knowledge of that can be helpful. There are other Arthritis Foundations that might be running groups and you can check with them and often there are many different ones, there are many websites on fire mileage and they may also sponsor groups.

The only thing I have to say about solo groups is that you need to be a little careful when joining a Farm Alger group because it is incredibly important that the group supports and reinforces positive thinking, so to speak, as opposed to a group where everyone they just complain about things, in reality you'll probably leave the group feeling worse, so proceed with caution, yeah, yeah, oh yeah, that's what the old terms were like. fire Malcolm and there are a lot of non-specific terms in the story, honestly I don't know the story, but what everyone definitely decided on is the term fibromyalgia.

It gets a little tricky trying to track things in the distant layer because it was often called other things, but yeah, now everyone has adapted to the fire chief. Yeah, oh, so the question is: do you taste good? Am I genetically predisposed or predisposed and my grandmother had rheumatism and what did that mean? We will never know. Yes, so you had a question, yes, so the question is methadone, which of course is a narcotic. In general, as a drug, I'm a fan of methadone, of course, methadone is known as the drug that heroin addicts pass on elsewhere. stop using heroin, but in fact it is a fantastic narcotic because it works for a long time with a very constant effect.

That said, in general, my experience with Farm Al Joe people is that they need higher and higher doses to control pain levels, so yes. Methadone will probably work to control pain, but people will probably need higher and higher doses and then begin to suffer the side effects of higher and higher doses. What I use is Northark instead of a different narcotic. It's a fun question. The answer is: you know? I'm saying, well, I wouldn't use one, but I'm sure if I were to resort to a trip, yes, yes, and I'm glad you asked that, so ask if the fireman just shows up in the bets, like this that I absolutely meant it.

It just pains me every time we send people into harm's way because I know, and the data is, that maybe even a third of them will experience PTSD and other issues that lead to these types of issues, so every time we send people into harm's way, foreigner and I'm not saying you know it's not necessarily doing that, but I know the impact on those guys' lives will be profound and can last a lifetime, yeah, that's a big deal, yeah, how long has it been described or discovered that? Malchus fire is attributed to this pain sent a sensitization syndrome, it is a difficult question to answer with almost any medical problem, there needs to be a kind of accumulation of data, a kind of development of a body of evidence before people start to change the way you think about it and particularly with something as complicated as this that had to be a big data development, so a lot of those things were developed in the late '80s, but they actually came to A more intense development of understanding of neuroscience in the 1990s. and the best studies came in the mid-2000s, so I think the idea started circulating probably 10 or 15 years ago and became more widely accepted in the last five to ten years, yeah, okay, thank you, thank you. all of you