[BLANK_AUDIO] Hello, this is Dr. Russell. I'm speaking to you from the studio in the University of Texas Health Science Center in San Antonio. I was on the faculty here the medical school for 32 years and retired in 2010. I'm no serving as medical director for Fibromyalgia Research and Consulting here in San Antonio, Texas. Welcome to another MOOC presentation on fibromyalgia. We're going to continue on from previous presentations with the concept of misconceptions. Fibromyalgia has been associated with and suffered from a number of misconceptions through the years, and we're going to talk a little bit about some of those. But first, we will look again at the state of the art description of fibromyalgia as being a common, chronically painful, soft tissue pain condition, which is characterized by persistent, widespread pain, tenderness and multisystem comorbidities. Fibromyalgia does not exist. That's a little bit like the News Week Article or the headline on the News Week front cover one time that God was Dead. So the other day, I was visiting with a cardiologist friend and when he learned that I was working with fibromyalgia, he said, well, I remember my teachers in medical school. They said fibromyalgia does not exist. And as I walked on the treadmill, talking to this cardiologist, I said, but, of course, it does exist. And he said, yes, I know. And in my mind, I thought, I wonder how much of what we now report to patients and we now use in the care of medicine is dependent on the biases of some of our teachers way back in the Ivory Towers. But if fibromyalgia does not exist, how is it that the American Psychiatric Association endorsed it, how is that the American College of Rheumatology has endorse two different criteria for this condition? The International Association for the Study of Pain has endorsed fibromyalgia as a clinical disorder. The World Health Organization has endorsed fibromyalgia as a clinical disorder. The Food and Drug Administration, with its very critical committees, of which I'm a member on one of those committees, looks very critically at medications and their indications and their value and their safety. And the Food and Drug Administration has approved three medications specifically for the management of fibromyalgia. There are over 7000 peer-reviewed publications in the medical literature. So not only did the author do the research or do the writing that was, that led to the publication, but a peer-review, scientist or faculty member or clinician had to review the paper and say that this is acceptable for publication. And then the editor of the journal had to also approve it. So over 7,000 such publications. If this is not convincing, I would suggest that the doubters cancel their membership in the Flat Earth Society. Another misconception, there's nothing wrong with people with fibromyalgia. When I first started as a young faculty member in a medical school faculty, I wanted to do research on fibromyalgia, and in fact, I wanted to do spinal fluid collection to evaluate the biochemistry of spinal fluid from people with fibromyalgia and compare it to healthy normal controls. I also at the time had a PhD in biochemistry, and so I thought I could develop tests that would help me to evaluate those spinal fluids and find some entity, some chemical in the fluid of spine, spinal fluid of patients with fibromyalgia not in healthy normal controls or in different concentrations than healthy normal controls. And that would help us understand fibromyalgia at the molecular level. So I approach, I, I pre developed such a study, designed such a study and then approached the institutional review board. And I was told, no, we can't approve you to do a procedure which has some potential risk, that is, collecting the spinal fluid, in people who have nothing wrong with them. So that was it. I couldn't do the studies. My response to that was to invite a colleague from Norway who had already done some studies on spinal fluid to come to the university medical school and to lecture. But his ticket, I would pay the ticket for him to come over from my research funds. But his ticket to come was to bring a collection of spinal fluids from healthy normal people and people with fibromyalgia that we could analyze and study in the laboratory. That happened the resulting paper was published and showed some very important abnormalities in the spinal fluid of people with fibromyalgia. And so I went back to the Institutional Review Board with that data, and the IRB was gracious enough and honest enough to say, well, perhaps we were wrong about our impression of fibromyalgia. And we will now approve your collecting spinal fluid to do further study. So that was a good resolution of that bias which was based on historical and previous experience of some of the people on the IRB, and they changed their mind. Another misconception is that people with fibromyalgia are all overweight. There is, in fact, evidence from a international Internet survey that people with fibromyalgia are heavier by somewhat, than healthy normal controls in society in general. There, there is other evidence to suggest that, in fact, fibromyalgia patients in San Antonio who were heavier than they should be were, in fact, not heavier than the average for a person the same age and gender in this city. And so with that evidence it would suggest that fibromyalgia patients were not heavier than the average population. And this perception of whether a person was heavier, the group were heavier or not might have had something to do with the society that were tapped to find fibromyalgia patients. So it's also possible that people with fibromyalgia might have gained weight for a number of reasons that related directly to the disorder. For example, people who have a lot of pain are likely to be less active, less physically active. And they might also be frustrated by their symptoms and might be trying to do something, which gave them gratification, historically as younger people or as children, and often, that can be eating. Another way of looking at this question is that older individuals tend to be heavier than younger individuals. But we don't generally castigate those older citizens just because they're a little heavier than the younger citizens. Finally, we did a research study here at the University of Texas Health Science Center in San Antonio evaluating samples from patients, blood samples from patients with fibromyalgia and comparing them to healthy normal controls. There were only over a hundred patients, and some of those individuals were overweight. We found in evaluating two chemicals, C reactive protein and brain derived neurotrophic factor that C reactive protein was elevated a little bit in the samples of the patients that had fibromyalgia. We try to characterize and understand that better, and we found that the individuals who had the elevated C reactive protein actually were the individuals in the population of fibromyalgia that were overweight. That was potentially important because there is evidence that fat cells, especially when they get engorged can cause the production of inflammatory mediators including C reactive protein. We went further and looked at brain derived neurotrophic factor which seemed to be associated with this population. And we found a polymorphism of the bone, brain-derived neurotrophic factor gene. A, a polymorphism means that the gene is a little bit different than the gene in the rest of the population or some other part of the population. And so, this suggests that there may be something unique about these individuals who are overweight and different in fibromyalgia, even genetically, than in the general population. Another misconception we can say is that fibromyalgia patients are all depressed, or that fibromyalgia is caused by depression, or that fibromyalgia should be treat, people with fibromyalgia should be treated for depression before we worry about their pain and other symptoms. Clearly this is an unsubstantiated bias because if we do epidemiologic studies, as were done at the University of Illinois at Peoria, the finding was that only 34% of people with fibromyalgia were depressed at the, at any point in time. And then it's hard to conceive the concept that fibromyalgia might be caused by depression, because there were over 60% of the population that were not depressed at any point in time. Mood and mood manifestations do not track together in therapeutic trials. That means that in treatment studies we have evaluated both the pain, the sleep trouble, the somatic manifestations of Fibromyalgia and tried to correlate them with the findings of depression assessment in Fibromyalgia. Even in patients who do have coexistent or comorbid depression, the depression doesn't change necessarily with treatment that results in a change in the severity of the pain or in the severity of the sleep trouble. So they are tracking separately. They are not pathologically related to each other in people with fibromyalgia, but they do travel together. And the frequency of depression is a little higher in fibromyalgia 34% than it is the general population at may be eight to 20% of people who are in the hospital for almost any reason, may have a frequency of almost 20% for depression. There have been a number of experiments looking at the frequency of depression and rather than going in to them in detail, I can tell you that when physician's biases about the likelihood of fibromyalgia patients being depressed were allowed, then the frequency of depression seemed to be higher in fibromyalgia. When phys, physicians could not activate their biases regarding the frequency of depression in fibromyalgia, then the frequency discovered was 34%. It's interesting that one of the chemical that we've studied in the spinal fluid of people with fibromyalgia is substance P, which is very elevated in these patients is also known to cause depression. And there is a chemical that has been developed that blocks the binding of substance P to its receptor, and when that chemical is given the symptoms of depression go away completely. Another issue is suicidality, because it can accompany depression. There is one country in the world where it seems that the number of suicides among fibromyalgia patients has been quit high. And interestingly, that is the country in which there is the greatest control of fibromyalgia care by psychiatrists. I'm not sure exactly what that means, but I think is important for us to take depression in association with fibromyalgia seriously in every patient we see. Another misconception is fibromyalgia patients are faking their illness for some kind of financial or other gain. Many important tests in medicine can be faked. But that seldom happens, and we usually don't worry about those tests, and someone faking those tests. You've all had the experience of the hammer being used, reflex hammer, being used to detect the reflexes at the knee or at the ankle. It is possible to fake a response to that strike by the reflex hammer, but most patients wouldn't know how to do it. And most patients wouldn't attempt to do it, and likewise, we don't think fibromyalgia patients on the whole, not, certainly, any substantial proportion of them, are making any attempt to fake their illness for gain. However, it has been a concern, in research studies that fibromyalgia patients might not improve, in the research study if their on disability already for fibromyalgia, and they have to defend that disability by staying sick. In fact, when people do, with fibromyalgia, do get disability funding, they have not gotten better as would be suggested by that philosophy. And finally, functional magnetic resonance images and experiments with those images have objectly confirm, objectively confirmed that allodynia, that is the pain and low pain threshold associated with fibromyalgia can be objectively documented. That is, what functional magnetic resonance imaging did was to measure the severity of the response by looking at changes that went on in the brain associated with a painful pressure, and that's not something the patient could fake or alter by any mechanism that they could control. And those kinds of tests objectively confirm that patients have the low pain thresholds and experience the pain of fibromyalgia. Another misconception, fibromyalgia is just stress. These patients can't handle the stress. My wife or my family can handle it. So they don't have fibromyalgia. And I'm not going to pay any attention to this person because they just need to get their life in order. Go home and get a life, some physicians or some healthcare workers or others have said. We should consider two different kinds of stress that might be referred to here, and that is emotional stress and physiologic stress. Physiologic stress might be like a cold or an infection or sinusitis that occurs, associated with the season of allergy. Or it might be a heart attack, or it might be something like an automobile accident. It might be both an emotional and physiologic stress to an individual. We did a research study many years ago, in which we asked the question, how many stressors are there in the lives of adults with fibromyalgia, compared to the number of stressors on the lives of people that don't have fibromyalgia? And our findings demonstrated conclusively that there are no more stressful events in the lives of people with fibromyalgia than in the lives of healthy normal controls. However, substance P, that chemical that is so high in the spinal fluid of people with fibromyalgia, and relatively uniquely that high compared to other medical conditions, this substance P is known to inhibit the normal function of the hypothalamic-pituitary adrenal access. This is referred to as the physiologic stress access. And so, this chemical that is now being blamed for many of the manifestations of fibromyalgia, can also be blamed for the patients with fibromyalgia inability, or lack of ability, or decreased ability to relate to stress or to deal with stress or to handle stress. So we think it's not that they are more stresses in the lives of people with fibromyalgia, but rather, that they handle those stresses less well because of this physiologic abnormality. Another misconception, fibromyalgia patients are just a bunch of complainers. So we could say, so the mafia's out to get you, but you don't have to feel paranoid about it. Fibromyalgia patients do indeed have many agonizing symptoms. Part of their may, mission in life may have come to be trying to find someone who will listen to them and ratify them. What caregivers don't like about fibromyalgia patients may be directly in response to the negation of the physician's of the disorder that these patients have. So this may be, sort of, a self-feeding problem and may be more the or as much the problem of the physician as that of the patient. Another misconception, fibromyalgia patients are hard to diagnose. Well, there is some truth to that, of course. Consider the effort required to actually listen to a patient's complaints, to actually think of fibromyalgia as a potential cause of chronic, widespread pain, to have learned how to apply simple diagnostic criteria, based on two simple factors. And how to explain the disorder to the patient, in a relatively layman's terms. Indeed, it's hard to diagnose fibromyalgia. Four times hard, as you can see. Fibromyalgia patients are hard to treat. There's some truth in this statement also. But it's also true of many conditions. It takes special learning and training. Perhaps that's why cancer patients don't go to policemen for treatment of their cancer. With some effort to learn how, anything hard can be mastered. With preparation and some experience, treatment of fibromyalgia can be very gratifying to the health care provider. I don't wish all physicians to treat fibromyalgia patients. But I think all can be respectful. And all can be kind. So in conclusion regarding misconceptions about fibromyalgia, we can say that many aspects of medicine are controversial, and fibromyalgia is one of them. People with fibromyalgia have long suffered at the hands of inattentive and tradition biased caregivers. Careless lack of understanding is harmful to the patients that the caregivers have trained and been dedicated to help. It's high time to set aside traditional biases in care. And so again, we meet the Happy Dog, who is happy because we are addressing misconceptions about fibromyalgia and finding ways in which we can better relate to our patients with this condition. Thank you. [BLANK_AUDIO]
