Fibromyalgia 101 With Dr. Shuchita Garg MD, Top Pain Physician In Cincinnati
Fibromyalgia 101 With Dr. Shuchita Garg MD, Top Pain Physician In Cincinnati
If you assumed that you were living alone with fibromyalgia, think again.
About 6 million people in the United States (primarily women, however there are men living with fibromyalgia) and millions more globally that can relate with what you're going through.
Perhaps it's not you but your sibling, child or associate that recently divulged their condition with you.
Practically anyone can develop fibromyalgia. But, there are patterns among individuals that are most likely to be detected with fibromyalgia syndrome (FMS).
Research revealed that women are more sensitive to pain stimuli than most men, and the level of sensitivity is specifically true when it relates to soft tissue and muscle mass analyzed by doctors.
Research have also revealed that women are more likely than men to consult with a physician when they experience pain.
It's important to eliminate any medical issues that might pose as an impostor such as, chronic fatigue syndrome, myofascial pain syndrome, or thyroid conditions, which we will touch on a little later.
Some physicians specialize in treating all forms of pain, such as neurologists or anesthesiologists. From experience, it's essential to consult with a chronic pain physician experienced with musculoskeletal pain syndromes to properly detect, diagnosis and treat your condition.
We've identified the top pain physicians in the United States and had the pleasure of chatting with Dr. Shuchita Garg, MD.
Don't worry, she remains abreast with the most recent scientific information about fibromyalgia treatment, symptoms, causes and medication so you're not stuck "physician shopping."
Dr. Garg, thank you for taking the time to talk with us, and congratulations on being nominated as one of the United States Top Pain Physicians.
Thank you so much for giving me an opportunity to talk to you.
I’m truly honored, and it's humbling to be in the revered list of top pain physicians.
I’m thankful to all who believe and trust in me. It motivates me to work harder and bring an effective change to improve the quality of life for my patients.
Please tell us about yourself.
I am an American Board of Anesthesiology (ABA) certified board super specialist in Pain Medicine and a specialist in Anesthesiology, with extensive experience in advanced field of medicine for about twenty (20) years.
Dr. Shuchita Garg, MD, Director of Pain Clinic, University of Cincinnati Medical Center (UCMC), Clifton Downtown Center, and Clinical Assistant Professor in the Department of Anesthesiology and Chronic Pain Management.
Your background and credientials are very impressive. Granted, we're familiar with chronic pain but it doesn't compare to your extensive experience.
(Laughing) I'm very flattered, thank you. Please rest assured that you're in good hands.
Nowadays, we're hearing more and more people being diagnosed with fibromyalgia.
The presence of fibromyalgia in patients has been observed for centuries.
In the past, it was referenced as fibrositis or myalgias. However, in today's world, the term fibromyalgia has taken over any presentation that involves widespread body pain that do not have an objective etiology to their symptoms.
A lot of referrals that I receive from clinicians in other specialties already pre-label and designate the patient to be afflicted by fibromyalgia.
With the vast information available on the internet and increasing awareness, I notice that patients themselves blame their chronic pain symptoms on fibromyalgia.
Unfortunately, I think it's become more of a blanket diagnosis nowadays.
Could you please explain what is fibromyalgia?
Yes, fibromyalgia is a chronic pain disorder that is characterized by diffuse pain, stiffness, and tenderness in multiple joints and muscle groups of the body.
However, this is more of a syndrome.
Pain in this condition is often associated with poor sleep, fatigue, generalized weakness, and headaches.
Various systemic disorders associated with this syndrome include Irritable Bowel Syndrome (IBS), Temporomandibular Joint (TMJ) disorders, and Interstitial Cystitis (IC).
Very often, diseases such as Ehlers-Danlos Syndrome (EDS), Rheumatoid Arthritis (RA), Systemic Lupus Erythematous (SLE) can lead to diffuse pain syndrome as well.
What are the tender points that doctors usually refer to when discussing fibromyalgia?
"Tender points" are certain areas of the body that are tender to digital palpation.
Tender points can be present at the back of the head, inner knees, and outer elbows. They can also be located in the neck, shoulders, outer hips, and upper chest.
A specific number of points must be tender to palpation to confirm the diagnosis, per the guidelines from 1990. But, these guidelines are no longer used as a reliable indicator of fibromyalgia.
I think readers will be interested to know, what causes fibromyalgia.
Initially, fibromyalgia was thought to be due to muscle inflammation.
However, the etiology of fibromyalgia is still uncertain and continue to baffle physicians worldwide. Much research is being put in to find out the exact causes fibromyalgia.
Genetics may play a role.
Some studies that used functional MRIs (fMRIs) in patients with fibromyalgia suggest that there could be a decreased activity in regions of the brain involved in pain inhibitory pathways. Altered levels and dysregulation of neurotransmitters such as serotonin or norepinephrine can result in bizarre processing of painful or not so painful stimuli.
Studies show that the regulation of the receptors and their sensitivities change at various levels along the pain pathway while transmitting signals from the site of pain to the brain.
Patients with fibromyalgia can have hypersensitization, or a more severe reaction, to even an innocuous triggering stimulus.
We often come across patients who endorse extremely painful responses, to mild pressure palpation of tender areas on their bodies.
They also complain of extreme sensitivity to temperature or barometric pressure changes and sometimes sensitivity to bright lights.
Hearing the words, "bizarre processing" as it relates to fibromyalgia symptoms, would make someone question if fibromyalgia is real, is it fake, is it a bipolar disorder or is it psychosomatic.
Patients wish to have a clear answer to their symptoms, which is very understandable.
As a chronic pain physician, it’s very challenging to have this discussion with patients and say that this is still under research and we’re still looking for the real culprit.
Oftentimes, there is a significant overlap of the illnesses which makes it even harder to explain.
There is a lack of a significant scientific research-based correlation between the severity of the disease and pertinent pathology.
Unfortunately, patients tend to think that their physicians do not believe them but that certainly is not the case.
Who are predisposed to be afflicted with fibromyalgia?
Fibromyalgia affects as many as 6 million Americans.
The symptoms can start at any age, however middle age is the typical age at which fibromyalgia is diagnosed.
It's not clear if psychological distress predisposes to fibromyalgia, but there seems to be a significant overlap with certain disorders such as anxiety, depression, IBS, collagen vascular diseases and rheumatologic conditions.
A lot of systemic disorders, as mentioned above, do not necessarily cause fibromyalgia but they do feature widespread pain as part of their presentation, which suggests that these could co-exist.
Is it true that women are at an increased risk of developing fibromyalgia?
Unfortunately, yes. Women seem to be more frequently affected, 3-5 times more than men.
In my practice, I predominantly see more women presented with this affliction.
We are still struggling to explain the female preponderance for this syndrome.
Some studies indicate underlying hormonal changes and others have indicated a tendency for this condition to go underdiagnosed in men to be a reason.
In general, there is a higher incidence of this syndrome in women with underlying rheumatoid arthritis, lupus, repeated traumas, insults or illnesses, be it physical or mental.
Having said that, it is not unusual to see men with generalized pain, but lately the numbers have been increasing.
Is fibromyalgia hereditary?
The genetic connection is still being researched.
Interesting. So, what are the first signs of fibromyalgia or common symptoms that you see in your patients?
Like I previously said, widespread diffuse pain in multiple joints, soft tissue, neck, and back are by far the most common symptoms.
Patients are very tender in physical exams, endorse marked and extreme tenderness (at times) to even slight touch on their back or joints.
They usually complain of extreme fatigue and tiredness with ill explained symptoms such as, generalized weakness or "pins and needles" sensations.
Does fibromyalgia cause insomnia?
Sleep is often the most affected.
I frequently see patients complain that they only get 3-4 hours of sleep at night. This is compounded by poor quality of sleep, which leads to frequent day-time naps and an exacerbated feeling of exhaustion.
Does fibromyalgia affect your brain?
Many patients complain about poor cognition and feel that they are not able to think clearly, which has been described in literature as "fibromyalgia brain fog."
Addressing mental health comorbidities with a pain psychologist or counselor should absolutely be on the top of the list.
A pain psychologist is a specialist who works closely with physicians in the chronic pain specialty and can provide access to resources such as cognitive behavioral therapies, biofeedback, acceptance and commitment therapies.
Some centers provide group therapy sessions, which is an extremely helpful tool as it exposes patients to patients who are having similar pain symptoms.
Interacting and discussing with them often make patients less overwhelmed and more accepting of their condition. It also empowers them to develop productive coping styles to help combat flare ups.
Imaging guided nerve blocks/joint injections or back and neck injections should always be considered to address the focal and specific areas of pain.
Discussion with your chronic pain physician can help shed more light on the available options and their associated indications and benefits.
In your experience, has fibromyalgia affected your patients quality of life?
All of these symptoms disturb their productivity and adversely affect their quality of life.
They express grief about not being able to be active, enjoy social gatherings or even participate in daily household chores or taking care of their kids and family.
Doctor, do you think there are any specific triggers that cause fibromyalgia to flare-up?
There are no definitive known evidence-based causes that can cause worsening of the symptoms of fibromyalgia.
However, worsening of symptoms is often associated with changes in weather or barometric pressures. Pain is usually reported as worse during the winter, and rainy, humid weather.
Patients usually describe a recent stressful event in their lives that caused exaggeration of their pain. This could range from a stressor related to their family, job, loss of a loved one, financial constraints or worsening of a chronic illness.
Repeated stressors are often responsible for anxiety, insomnia and disruption of coping mechanisms, which can add to the heightened pain responses.
How is fibromyalgia diagnosed?
The diagnosis of fibromyalgia is mainly based on getting a detailed history and physical exam of the presenting symptoms.
It is essential to keep in mind and discuss any pertinent pathology that can result in or co-exist with this condition.
In my opinion, it is imperative to address the coexisting co-morbidities and emphasize on their management as well, to be able to manage this complex condition.
How does a Rheumatologist diagnose fibromyalgia?
The American College of Rheumatology devised criteria to help with the diagnosis of fibromyalgia. These include combining the rating the number of areas that have pain along with the severity of somatic symptoms such as fatigue, poor sleep, and poor cognition.
The duration of symptoms should have been for at least three months, and no other disorder should be able to explain the diagnosis better.
So, is there a fibromyalgia diagnosis checklist?
It's a massive source of frustration, for both the patient and physician, because there is no gold standard test to confirm the diagnosis of fibromyalgia objectively.
I sometimes discuss ruling out vitamin deficiencies, especially Vitamin D and B deficiencies, thyroid function tests and sometimes referral to rheumatology to rule out seronegative arthropathies.
Lack of significant correlation between the presenting symptoms and a plausible confirmatory test leads to multiple physician and specialist visits, endless lab tests, imaging, and interventions, which result in a significant burden on the economy.
What are the different ways fibromyalgia can be treated?
It's important to understand that fibromyalgia is a syndrome.
By now, we know that it involves dysregulation of the pain pathway at multiple levels.
Therefore, it's important to emphasize to patients that the mainstay of management of fibromyalgia is to offer a multimodal approach towards managing their symptoms.
Having an interdisciplinary participation of the primary care physician, rheumatology, and respective specialists could be immensely helpful to have all the participating physicians on the same page. This not only adds to a sense of security in the patients' mind but it also ensures that unnecessary interventions are avoided.
Adapting a healthy and active lifestyle may seem like vague advice, but trust me, it's key to preventing further decline with this disease.
Being that fibromyalgia is painful, how can someone think about exercising, more or less incorporate an active lifestyle?
Implementing a daily exercise schedule not only helps to strengthen the core and build muscle tone but it also releases endorphins, which are the strongest pain killers known to exist.
Swimming / aquatic based exercises are a great tool that could help reduce pain as the muscles and joints feel lighter in water.
I would also encourage patients to explore options like yoga, tai chi and other forms of exercise modules, which could be done in groups with the help of a trainer.
Acupuncture, massage therapy and myofascial tissue release have also been recommended.
What is the best medication for fibromyalgia pain?
So far, the Food and Drug Administration has approved three medications for treatment of fibromyalgia, which are pregabalin, duloxetine, and milnacipran.
Pregabalin works on the calcium channels and blocks the hypersensitivity related to the nerves.
Duloxetine and milnacipran are basically anti-depressants that help restore the chemical neurotransmitter imbalance.
NSAIDs or muscle relaxants could be used as adjuncts for symptom-based treatment or flare-ups.
It's important to note that opioid based treatment has not been associated with favorable long-term outcomes in this population of patients. Moreover, the risk versus benefit ratio of these medications does not make it a lucrative option as a first line medication for pain relief in this condition.
Dr. Garg, in your opinion, are there any immediate measures one can make at home to relieve symptoms of fibromyalgia?
I'm sure patients can undertake several steps at home that can be beneficial.
I would say, start with focusing on good sleep hygiene. Set a time to go to sleep and wake up in the morning and avoidIng daytime naps is a great start.
Avoid caffeine, and alcohol before bedtime.
Consider techniques such as meditation, deep breathing and relaxation exercises to combating stress is strongly recommended along with pharmacologic treatment such as, sleep aids or anti-anxiety benzodiazepines.
Regular physical activity and exercise are absolutely recommended to prevent deconditioning, which can add to pain symptoms.
I always emphasize the role of exercise to patients and mention that they should start with simple exercises, such as stretching, walking in or around their house and then gradually advance to increased activity levels.
Last but not the least, developing strong coping styles to deal with flare ups would help get through the days when pain is excruciating.
Maintaining a positive attitude, and not giving up is easier said than done but it's not impossible.
Is there any specific diet advisable for fibromyalgia?
Dietary measures have been suggested for improving the symptoms of fibromyalgia not no evidence-based medicine has shown a proven beneficial effect.
These include high-energy foods that are low in sugar, gluten free, and not eating additives and excitotoxins.
Food rich in magnesium, zinc, and omega-3 can help because their deficiency has been found to cause increased pain in patients with fibromyalgia.
There is a definitive need for more research to investigate effects of diet on fibromyalgia. I think there is certainly no harm in trying these options along with the prescribed therapy.
What's the prognosis? I mean, is there a chance that fibromyalgia might improve with time?
Fibromyalgia is a chronic disease that may often be a lifelong condition.
It sometimes can become debilitating due to the multitude of symptoms, it is not known to cause structural damage to the joints or other body organs.
It is essential to catch the symptoms at the earliest stage and do symptom-based management.
Is it true that fibromyalgia can affect pregnancy?
In some cases, women have reported improvement in their symptoms during pregnancy.
On the other side of the coin, for some women, there may be an exacerbation of fibromyalgia symptoms, especially during the first trimester.
Some usual pregnancy complaints, such as fatigue, stress, and mood swings as a result of changing hormones, may be worse for women with fibromyalgia.
It's important to remember that none of the medications approved for the treatment of fibromyalgia have been deemed to be safe during pregnancy.
Dr. Garg, what is the difference between fibromyalgia and chronic fatigue syndrome?
Chronic fatigue syndrome and fibromyalgia are comparable in numerous ways.
The main symptom of fibromyalgia is pain, whereas the main symptom of chronic fatigue syndrome is extreme tiredness that is not relieved with sleep and rest. Commonly people refer to this as "fatigue".
Hypothetically speaking, if I'm diagnosed with this ailment, will I be able to continue working with fibromyalgia?
Yes, work continuation can be challenging with every day and persistent pain symptoms. It is not uncommon to see patients getting frustrated and turn to disability claims for this reason.
However, I would strongly consider continue working, but at the same time, incorporate beneficial lifestyle changes.
One can try modifying their work ergonomics. Though not always possible, and I understand that its easier said than done, try cutting down on the number of hours worked, or switch to a less stressful job.
If one continues to face challenges at work, consultation with an occupational therapist can be beneficial.
What is the outlook for fibromyalgia?
Currently, there is no definitive remedy for fibromyalgia.
Nevertheless, lifestyle changes, along with multimodal approach toward pain management can reduce the likelihood of flare ups and aid in the treatment of fibromyalgia.
Fibromyalgia is an ailment that can be managed, and afflicted patients can continue to partake in usual daily chores and enjoy a quality life.