Fibromyalgia: A Disorder of Pain Processing with Dr. Benjamin Abraham

Podcast Transcript

Nada Youssef:   Hi. Thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Doctor Benjamin Abraham. Thank you so much for being here.

Dr. Abraham's a pain management specialist in the Department of Pain Management here at Cleveland Clinic, and today we're talking about fibromyalgia.

So, please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. So, before we jump into the topic, I'm going to ask you some questions just to get to know you on a personal level.

Dr. B. Abraham:  Oh, sure. Thanks for having me.

Nada Youssef:   Sure thing.  So, best meal you've ever had.

Dr. B. Abraham:  Oh. That'd be a local favorite, Melt Bar and Grill. I'd say it's a bacon cheeseburger.

Nada Youssef:   Bacon cheeseburger. I've never had that one. I'll have to try that one. Good. All right. So, how about fiction or non-fiction, whether it be books or movies, what is your favorite?

Dr. B. Abraham:  Oh, I'm a big movie buff. Definitely action movies. I grew up on the cheesy 1980s, 1990s action movies, Arnold Schwarzenegger, so ... But as far as reading goes, it's mostly non-fiction, biographies. Part of what got me into medicine was biographies of doctors and scientists. I just found it so interesting.

Nada Youssef:   Excellent. So, you watch a lot of documentaries on Netflix, and all the good stuff?

Dr. B. Abraham:  I do, yeah.

Nada Youssef:   I'm a buff for those, too. So, how about if you weren't a physician today. What would you be?

Dr. B. Abraham:  Wow. Maybe unemployed, but maybe ... I think something in healthcare, whether it be nursing or dentistry or maybe an engineer, a biomedical engineer, if I couldn't choose anything in healthcare. But, helping people has been super satisfying, and so I can't imagine myself doing anything that didn't involve service.

Nada Youssef:   Great. Well, very happy to have you here, and as a physician. So, let's talk about fibromyalgia. First of all, let's just talk about what it is.

Dr. B. Abraham:  Well, fibromyalgia, you know, when doctors are talking amongst themselves, we're really talking about a chronic, meaning greater than three months, widespread muscle and joint pain. Now the thing about that definition is there are many, many diseases that could fall into that category.

So, when we get into the nitty gritty, we'll tease out more about what really this widespread musculoskeletal pain really is. Patients often have multiple different symptoms that in times past were written off as crazy, or hysterical, or making it up, or all in your head. And so, these various symptoms which we're going to talk about, manifest mostly in this widespread pain.

Nada Youssef:   So, when you say muscle and joints, is that in a certain place on the body, or is that all the muscles, all the joints?

Dr. B. Abraham:  So, the rheumatologists had tried to differentiate, diagnose, really put a finger on what it entails. They came up with widespread pain, meaning upper and lower body, left side and right side, and so this can most commonly be neck pain and back pain, but can involve tenderness, pain in any of the upper and lower extremities, arms and legs.

Nada Youssef:   So then, when patients come to you, did they already Google it? Did they already come saying, "I think I have fibromyalgia?" Or how is it diagnosed by you, as a physician?

Dr. B. Abraham:  Well, I'd say it's a mixture of both. Many patients, with the wonderful internet we have, have done their research, and that's great. But, I'd say the other half of the patients may have been diagnosed with something else, rheumatoid arthritis, lupus, multiple sclerosis, anxiety, or depression, and that may be the diagnosis that they're coming for in their chart.

Either way, knowledge is power. These patients who have read about the disease often ask the best questions.

Nada Youssef:   Sure. So, is it common that fibromyalgia is usually paired with a different disease?

Dr. B. Abraham:  Fibromyalgia, essentially, is a syndrome, meaning that a collection of symptoms, so pain here, pain there, migraine, problems with the stomach. All these fall under this umbrella and scientists and historians noticed that all these symptoms were falling under the same umbrella together. So, this syndrome, this collection of symptoms, really has been occurring together for a long time. We've recognized this since the 1800s.

So, these patients will come with other diagnoses. Often, it's one of these diagnoses that fits under the umbrella of fibromyalgia.

Nada Youssef:   So, what other doctors can diagnose fibromyalgia? Is it only a pain specialist? Can your primary care physician? Or who could?

Dr. B. Abraham:  That's a good question. Many patients might assume that you'd have to go to a pain management doctor to get an accurate diagnosis of pain. But think about if I've spent many years out in the sun, I come to my family doctor. He noticed a suspicious mole on my face, then well, I would certainly want him to point that out, make that diagnosis.

So, whether your family doctor, or your rheumatologist, or orthopedic surgeon decides to mention to you, it's important either way. They can refer you to a specialist if they don't feel comfortable making a definitive diagnosis themselves, in much the same way that if I saw a suspicious mole, I would say to a patient, "Let's get that checked out by an expert, since I don't feel comfortable being the be-all and end-all for your skin mole."

It varies, how patients come to me. Some of them refer themselves. Some of them are referred by their family doctor. Some of them are even referred by a different pain management doctor in the community if their symptoms aren't getting better with conventional treatments.

Nada Youssef:   So, then if symptoms aren't getting better with just the primary care physician, then they would be referred to a pain specialist like yourself.

Dr. B. Abraham:  What we really want to do is make sure patients get the proper treatment, and workup, and diagnosis, wherever they can. With the pressures of the American healthcare system and the frustrations that leads to for patients, we really want to make sure that whoever can make the diagnosis, does. If they are getting better with these conventional treatments, that's great. They would never even need to cross my door.

So, these patients who have these widespread pains can ultimately get a diagnosis from anyone.

Nada Youssef:   Sure. So, let's talk bout some of the most common symptoms that you hear from patients with fibromyalgia, what they say to you, and what to look for.

Dr. B. Abraham:  Besides the widespread pain, the muscle and joint pain, patients are typically presenting with headache. They're also typically presenting with some kind of abdominal disturbance, so say, diarrhea, constipation, or both. In fact, they may have been diagnosed in the past with IBS, irritable bowel syndrome. They may have some kind of pelvic pain that came to the attention of their gynecologist. They may have some knee arthritis, for example, superimposed on this pain, and so they may have found their way to an orthopedic surgeon to try to get all this worked up.

Another interesting phenomena that seems to occur with patients, is something called POTS, which is essentially, patients lay down. If they stand up really fast, they get dizzy. They might find their way to a cardiologist in the pursuit of working this up, and so, this phenomenon obviously is not made up, obviously not in their heads. Often they are taken very seriously and get a thorough workup for this condition, leaving aside some of the other problems, like anxiety, depression, that may co-occur with the muscle and joint pain.

Nada Youssef:   So, sounds like fibromyalgia is a little bit hard to pinpoint where there's so many issues that can come with it.

Dr. B. Abraham:  Well, it has a lot of mimickers. Various conditions, rheumatoid arthritis, lupus, can often mimic these same conditions. Inflammatory bowel disease, so in your immune system attacking your intestines in instances such as Crohn's disease, can cause not only disturbances in your abdomen, in the intestines, but also joint pain, eye problems, skin problems, and so you might not expect that something in the intestines would have such global effects, but it really does.

Same story with fibromyalgia, so these patients are often heading down multiple rabbit holes with multiple different specialists, which is why they're so frustrated.

Nada Youssef:   Right. Right. It's hard to pinpoint. So, the immune system is attacking the body? Is that accurate? Is it an autoimmune disease?

Dr. B. Abraham:  Well, that was originally what we thought. Now, the name of fibromyalgia, the syndrome that we speak of today, went through various names in the past, fibromyositis. For all you English nerds, Latin nerds out there, the itis, the inflammation part of that really suggested that either it was some virus, some infection, some fungus, versus your own immune system attacking your own body and then causing inflammation. And so that itis, like tonsillitis for example, really was one of those rabbit holes that scientists, physicians, were chasing for a long time.

Since then, we've done the research to check the muscles, check the joints, look for inflammation, and in many cases, it wasn't found on these biopsies. Didn't have a good explanation for that until we understood more about the brain, the spinal cord and the pain processing nerves.

Nada Youssef:   Okay. So, what causes it? That's my next question.

Dr. B. Abraham:  We don't actually know, or fully understand, what causes it. Now, if you check brain scans, PET scans of patients, you can actually see neuroinflammation. That's a fancy way of saying that the pain nerves are inflamed. They're irritated. You can't fake that.

And so, when compared to patients who have no symptoms of pain, and when we look at these patients with fibromyalgia and the various co-existing symptoms, tiredness, exercise intolerance, headache, GI disturbances, there seems to be a pretty convincing correlation between those symptoms and this neuroinflammation.

So, we're beginning to understand fibromyalgia as a disease of pain processing, rather than local inflammation in a muscle. Looking back in the history books, we know that lots of diseases were mistaken in the past. HIV is a prominent example from when I was growing up. At first, it was considered to be a result of hard partying. HIV and AIDS was then subsequently named, GRID, Gay Related Immune Deficiency, thinking that the lifestyle of homosexual men included hard partying, promiscuous sex, and so scientists, unfortunately, when I was a kid, thought that there might be some correlation rather than an actual virus.

Looking back a little bit further in the history books, schizophrenia was mistaken for demons inside the skull, so people would drill holes in the skull to try to let the demons out. Looking back on it now, it seems crazy, but we have a lot of examples where diseases that we now understand were really thought to be-

Nada Youssef:   Some mystical-related stuff.

Dr. B. Abraham:  ... some mystical cause. So, we're really making a lot of breakthroughs in the science. The term, all in your head, really doesn't apply if you look at the science.

Nada Youssef:   Sure. Sure. And just like you mentioned, neuroinflammation, I didn't even know there was such a term that existed. It sounds like it would just affect everything if it started in the brain. And speaking of all in your head, that's my next question. So many patients hear it, "It's all in your head," so I want to talk about why people ... I mean, we talked about why people talk about that, but people that hear about that, and hear that it is just in your head, or maybe some doctors are not helping them, what can they do to get better?

Dr. B. Abraham:  Well, the patients hear that a lot because if they have many problems that are existing at the same time, often it's overwhelming for the primary care doctor or the specialist to hear all about these problems. One of the things that we're finding is that treatment of fibromyalgia as a disease tends to improve many of these symptoms together. So, rather than seeing 10 different specialists for 10 different problems, migraine, abdominal pain, diarrhea, treatment of fibromyalgia, either through medicines or non-medicine treatments tends to improve their function.

In many ways, I wish the sign on my front door said, functional improvement, because really, that's what we're looking for. So, any treatment we suggest is going to be focused on improving the patient's function.

Nada Youssef:   Sure. Sure. So, fibromyalgia isn't life-threatening. Correct? But it can affect a person's life in a lot of different ways. Can you explain the complications of this disease?

Dr. B. Abraham:  Absolutely. As an anesthesiologist by training, we look at life-threatening in a somewhat different way. You might ask someone on the street, "Is cancer life-threatening?" They'd say, "Yes. It can be." You might ask someone, "Is depression life-threatening?" They might say, "No."

But, for example, if a patient has severe depression that's coexisting with fibromyalgia, it may be so severe that they're suicidal. As an anesthesiologist, we know that there are many treatments where we're classifying a patient about to undergo anesthesia as an emergency, as a life-threatening emergency. One I can think of very clearly is, ECT, this electroconvulsive therapy that is used as a last-ditch effort, quote-unquote, by psychiatrists. These might be otherwise healthy patients who have severe depression that is threatening to their life.

So, when we talk about life-threatening, in some ways we have to expand that definition. I really like the anesthesiologist definition, where there are many ways in which your life can be altered, harmed, and even threatened. If we're looking at fibromyalgia, these patients typically get a breakdown in their social relationships, their family relationships. They lose social support that's so critical for a patient with a disease to recover, so maybe we need to expand our definitions here about life-threatening, and maybe it's better to even talk about it as life-altering. It is a severe, life-altering disease. If left untreated, really ruins people's lives.

Nada Youssef:   Sure. And there's more than one thing to this equation to make it this complicated disease.

Dr. B. Abraham:  Absolutely.

Nada Youssef:   So, what treatments are there for this disease? And if you could mention also some non-opioid treatment options?

Dr. B. Abraham:  Sure. Whenever we talk about treatments for any disease, we want to first talk about proven treatments. We want to talk about we're-not-sure treatments, the gray area, and areas that we need to do some more research in. And then, treatments that we've tried and proven in a rigorous research setting that they just don't work. If I have a stroke, I don't want to go to the doctor and have him suggest eating frogs legs. We want to do proven treatments only, and you wouldn't accept that with any other disease process, so with fibromyalgia, it's especially important to only pursue treatments that are proven.

So, as far as treatments, we touched a little bit on that earlier. There's both medical, the medicine, and non-medicine treatments for this. One hallmark of fibromyalgia is that these patients tend to be very medicine-sensitive, and we don't exactly know why. But, I can tell, looking at my schedule in the morning, a patient with widespread pain who has multiple allergies, already it's on my radar that maybe they have fibromyalgia. Let's touch on that during their appointment.

And so often, you'll find patients with fibromyalgia have intolerances to the conventional, FDA-approved treatments. So, as far as medicine treatments go, if you would come to your family doctor with widespread pain, you've had it for greater than three months, it's in the upper and lower body, the left and the right side, and they suspected fibromyalgia, they might try you on a medicine like duloxetine, or pregabalin, or milnacipran. And so, these three medicines work in different ways, but all seem to treat these symptoms.

When we say, treat, that's an important word, because what do we really mean by that? Patients with fibromyalgia often need multimodal, many modes of treatment together, in order to get them their lives back, in order to restore their function. So, patients in my practice will often need both a medicine and a non-medicine treatment.

So, medicines not being the mainstay here, we often talk about patients using tai chi, patients using meditation, patients using cognitive behavioral therapy, as examples.

Nada Youssef:   Great. Earlier you mentioned that these patients tend to be medicine-sensitive. Are you talking about the side effects of medicine really affect them, or what do you mean by medicine sensitive?

Dr. B. Abraham:  Absolutely. Yeah. These patients, especially in my practice, I'm finding that they tend to have the side effects that one might see, they tend to have them more frequently. Every medicine has a side effect. The question is, does the patient notice it? Does the patient have a risk versus benefit discussion? "Maybe I have minor side effects from this antibiotic, but it's important to clear up my infection, so I'll continue to take it." The math doesn't always add up in that way with a patient with fibromyalgia, because they may have severe side effects from various medicines.

Nada Youssef:   Right, and other issues that they may have, as well.

Dr. B. Abraham:  Right, and we don't fully understand why that is, just yet. We're just scratching the surface insofar as the lab science and the research trials.

Nada Youssef:   Sure. So, let's talk about cognitive behavior therapy and how that can help patients. What kind of things go on in a cognitive therapy session?

Dr. B. Abraham:  So, CBT, cognitive behavioral therapy, is very important, because essentially it's ... People have heard the word, psychotherapy, before. It's goal-oriented psychotherapy. It emphasizes changes in thought patterns and behaviors, rather than, we're talking about deep insights you might see on TV, happen during psychotherapy.

A patient might say, "Well, I have a broken leg. It's causing me pain. Therefore, my life is ruined," and we know if we can break that chain, we can actually change the thoughts and the behaviors of the patient, we can actually improve their function.

So, there's been research trials about this, and they've really shown that there's been global improvements in function, global improvements in pain rating, and these are sustainable even when we're talking about patients who are not taking any medicines at all.

Nada Youssef:   Right. Right. So, are you helping them change their perception, or something like that, when it comes to the pain that they're dealing with? Is that what CBT's about?

Dr. B. Abraham:  Well, in plain terms, yes. Many patients have pain, and not all of their lives are ruined by it. And so, if we can break that cycle of pain, suffering, and social and relationship dysfunction, we really can help these patients. So, breaking that chain of events is really one of the goals of cognitive behavioral therapy. We work with psychologists. Most recently, we're working with psychologists on a shared medical appointment to integrate both the psychological approach to treatments, disease, as well as the medical approach.

Nada Youssef:   So, with the shared medical appointments, can you talk a little bit about that? Because patients are using shared medical appointments for this diagnosis, describe what that is, and why it's beneficial for these patients.

Dr. B. Abraham:  A lot of diseases are very isolating. If you have a broken leg, everyone has sympathy for you for the 12 weeks that it takes for it to heal. But, imagine if you had this broken leg for 10 years. Your family might get a little tired of hearing about your broken leg. They wouldn't what to sign your cast at year 10, compared to day one.

So, fibromyalgia is very isolating, and patients often become shut-ins because of the pain. Getting these patients together with patients with similar problems often has a beneficial effect on the pain. We're only now coming to understand that, in regards to diabetes, cancer treatment, high blood pressure, patients with heart disease.

So, this model of a shared medical appointment really pairs the patient up with people going through the same problem that they have, providing social support for them, and ultimately makes the treatments that we're offering more effective.

Nada Youssef:   Sure. Sure. So, then it's a bunch of patients supporting each other and also a physician is in the room?

Dr. B. Abraham:  Right. Right.

Nada Youssef:   Is there a psychologist as well?

Dr. B. Abraham:  So, the way we've structured it is, it'll be a one-hour appointment with a physician, myself, my colleagues, some of whom are anesthesiologists like me, some of whom are rheumatologists, some of whom are neurologists, and we spend an hour with the patient, really talking about the newest research and answering their questions. That's hard to find in a disease like fibromyalgia. It's very hard to have the undivided attention of both your peers and a physician.

After that one hour, we're spending another hour with these patients with a pain psychologist, someone who's specializing in these psychological treatment methods. So, this two-hour appointment really packs quite a punch as far as treating it, getting these patients back to functioning.

Nada Youssef:   Sure. And with the psychologist, is that then him or her would explain about meditation? Do you guys kind of go over what meditation is, and how it can help, and how you could do it at home or anywhere? I mean, is that something, a big point of this, I hope?

Dr. B. Abraham:  Really, once the patients hear about the methods of cognitive behavioral therapy, they can take those home and implement them in their daily lives. One of the things that patients don't want to do, is commit to lifelong psychotherapy. But, if we can give them the tools to get better, they can implement that at home and recover.

Nada Youssef:   So, how do you think meditation helps?

Dr. B. Abraham:  Well, we're not sure, exactly. We're seeing functional benefits with meditation in a lot of different disease processes, fibromyalgia included. And so, we're not sure how it's working. We're not sure why it's working, but there have been some small trials of it that have shown a benefit.

Most importantly, these treatments, these psychological treatments, these alternative treatments, when paired with conventional Western medical treatments, seem to yield the greatest improvements. So, that's really what we're focusing on in the shared medical appointments, is pairing the mind and the body approach to treat these patients.

Nada Youssef:   That's excellent, because meditation's very helpful, I mean, stress, anxiety, anybody, really.

So, I want to talk about the different Cleveland Clinic specialists that you would be working with. So, if the pain is targeted in an area, are you working then with a different specialist? I know you mentioned earlier a rheumatologist could be in the room?

Dr. B. Abraham:  Right.

Nada Youssef:   If someone had IBS or some kind of gut issues, do you work with Digestive Disease Institute? Do you get to do this kind of work?

Dr. B. Abraham:  We share quite a few patients with these different departments that ... At the present, we're working with rheumatology closely, anesthesiology, and pain psychology together, on the shared medical appointments. Looking to expand soon, but that's in the works.

Nada Youssef:   Great. That's excellent to hear.

All right. So now I want to talk about diet and exercise when it comes to this disease. Diet affects everything and everyone, so that's very important to talk about. With exercise, I want to emphasize about how patients with fibromyalgia are in pain. They're in pain in a lot of ways in a lot of their bodies, and how are they supposed to exercise with that pain, and what to do?

Dr. B. Abraham:  That's a common question we get, and that's why these trials with tai chi were so exciting. If you look at patients who were formerly very active. They were marathon runners. They were power lifters. And now, even just doing yoga, they can't do anymore. So, patients often feel like, "Well, I feel like I've been beat up all over. I feel like I have the flu." How can you ask this patient to do an intensive exercise program?

These research trials on tai chi were so exciting because this is a ancient martial art that is gentle, is slow, is low intensity, but also seems to yield some pain relieving benefits for these patients. So, it's both exercise, as well as treatment.

Nada Youssef:   And you said, it's tai chi?

Dr. B. Abraham:  Tai chi.

Nada Youssef:   Is it like more movements for ...

Dr. B. Abraham:  Yeah. It's very slow movements, very gentle movements. The nice thing about having the internet now, is you can type in-

Nada Youssef:   Google it.

Dr. B. Abraham:  ... You can google it, and you can really find many, many instructional videos online free of charge. There are many classes at your local YMCA community centers. And so, patients can find those locally in their community, oftentimes, or look on the internet and easily find some beginnings.

Nada Youssef:   Can I have you spell it for me? Tai chi?

Dr. B. Abraham:  T-A-I C-H-I.

Nada Youssef:   Perfect. All right. Cool. So, how about like, water aerobics? Is that something ... Because you would think, you know, in the water, it just ... You feel lift, you know, you ...

Dr. B. Abraham:  Many of our patients sort of graduate to water aerobics, water therapy. It's not the first thing I would suggest to a patient, since patients coming to my office have often already had physical therapy. Often, their pain was worsened with motions that when used alone didn't help them recover. So they really have a bad taste in their mouth.

If we treat these patients with many different modes of treatment, including tai chi, taken together, these all seem to help.

Nada Youssef:   Okay. So tai chi, it is. Let's try that one, too.

So, let's talk about diet. I would think some kind of anti-inflammatory diet, and then what you think is the ideal diet? I like to always ask the doctors this question. So, I'd like your take.

Dr. B. Abraham:  I wish I knew. Ask me when I'm 110. I'll be able to tell you. But, there's been a lot in the press about turmeric. As an Indian, I can tell you all about turmeric. I just can't tell you how much of it to eat. And that's the key about diet. We are in the process of doing research trials in the medical community, but don't have any definitive answers as to what the dose would be, how often to take it.

When we look at populations around the world, who are living a long, functional lives, we know that avoidance of processed foods, avoidance of high carbohydrate, high sugar foods, seems to be the common denominator. When you look at the Japanese, the Greeks, there are lots of folks there who are living into their 90s and beyond, and living well. Their diet seems to be less processed foods, more whole foods, more natural foods, and lower intake of carbohydrates.

Nada Youssef:   Right. Now, you mentioned turmeric. So, for those that don't know, it's a very strong, yellow, orangey spice, but anti-inflammatory. Right?

Dr. B. Abraham:  It seems to be, and we don't exactly know how to translate the lab results, what the scientists are finding at the bench in their laboratories. How do we translate that to humans?

We know of plenty of examples of that. If you think about treatment after a knee replacement, in animal models, it seems that anti-inflammatory medicine, so Advil and Naproxen, medicines such as that, seem to block bone healing in some animal models. And you might think, "Well, then no human should take an anti-inflammatory medicine after their knee replacement." As it turns out, anti-inflammatories are very effective to treat the pain of a joint replacement, and we haven't solidly been able to prove that in humans, these medicines interfere with healing or make a worse outcome.

So, the bench research doesn't always exactly translate into the real world of today, and so we have to be careful about extrapolating benefits of any food, prescribing that to a patient, especially when the supplement industry currently isn't regulated. Many products are manufactured overseas, and you're not even really sure what you're getting in there.

Nada Youssef:   Right. And I was just going to ask you about the supplements because, you know, because sometimes, people don't cook with turmeric, or don't know how to cook it, or don't know how much to put in their food, so they'll hear, "Oh, just get a supplement." But again, not FDA approved and it's one of those things that maybe help, but we don't have the research.

Dr. B. Abraham:  Right. We don't have the research, and more importantly, it's not regulated. I always want to suggest to my patients that they focus their energies on treatments that work, treatments that are proven. Often, these diseases are depleting patients financially. Sending patients down rabbit holes of, "Well, maybe this might work. Might as well try it," gets expensive.

Nada Youssef:   Right. Can only imagine. Okay. Well, I have one more question for you. So, I just want to have you give advice, or strategies for patients to manage their fibromyalgia, you know, like we're talking about diet, exercise, tai chi, just what you have to say to our patients that are struggling with this disease or syndrome.

Dr. B. Abraham:  Well, knowledge is power. Read as much as you can. Learn about the disease process. If you think that you have it, attend one of our shared medical appointments, talk to your family doctor about it, come into the office to see either myself or one of my colleagues. Talking about it, working through all the intricacies of the disease that we're just now coming to understand, is important since education is really going to help these patients take care of themselves.

Nada Youssef:   Yes. And there's not just one approach. Everybody's different. Every fibromyalgia patient is different.

Dr. B. Abraham:  We tailor the approach to each patient. What we're finding about this syndrome is that all these symptoms fall under the same umbrella. With a generally applicable skeleton of treatment, we can get these patients feeling better.

Nada Youssef:   Sure. Well, thank you so much. It's been very informative. Very nice to have you.

Dr. B. Abraham:  Thank you.

Nada Youssef:   And thank you again, for all of our listeners who joined us today. We hope you enjoyed this podcast. And to learn more about pain management, you can visit clevelandclinic.org/painmanagement, or to make an appointment with Doctor Abraham, you can call 866-320-4573. And to listen to more of our Health Essentials podcasts from our Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcasts, or you could subscribe on iTunes. And for more Cleveland Clinic health tips, news, and information, make sure you follow us on Facebook, Twitter, Snapchat, and Instagram, at clevelandclinic, just one word. Thank you. I'll see you again next time.

Dr. B. Abraham:  Thank you.

Nada Youssef:   This concludes this Cleveland Clinic Health Essentials Podcast. Thank you for listening. Join us again, soon.