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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

Lady Gaga, Fame, and Fibromyalgia

Pain management expert, Don L. Goldenberg, MD, provides a professional assessment of this pop icon's battle with mood disturbances, sleep difficulties, and chronic widespread pain from fibromyalgia, a condition affecting some six million Americans.

I was taken aback when one of the journalists who works with Practical Pain Management called me last month to ask if I knew that Lady Gaga had just postponed her European tour because of an exacerbation of her fibromyalgia. I never had a clue that one of the most famous artists in the world had been diagnosed with fibromyalgia.

A statement released via Twitter on Sept. 14, 2017, proclaimed that she was “suffering from severe physical pain that has impacted her ability to perform.” Shortly thereafter, Gaga tweeted that she was suffering from fibromyalgia, an illness that I have been studying for 40 years. Around the same time, Netflix released the documentary film Gaga: Five Foot Two and reviews of the film mentioned that Gaga opens up about her “overwhelming pain”.

Lady Gaga shares her struggle with Fibromyalgia in a Netflix film.

For me, this was a perfect storm for many of my life-long interests. Rock and pop music is a passion for me. I also consider myself a film buff, so I was anxious to see if the documentary on Lady Gaga might fall into the same class as classics like Scorsese’s “The Last Waltz” or Demme’s “Stop Making Sense”. But most importantly, as an international authority on fibromyalgia and related disorders,1 I was professionally and personally invested in what Lady Gaga might say about her illness and any subsequent good or bad fall-out.

What follows is my analysis of the documentary in terms of how it fits with mainstream fibromyalgia information and how I see Lady Gaga fitting into the spectrum of the thousands of patients I have treated who suffer from this condition. It is important to disclose that I have never spoken to or interacted with Lady Gaga; I have not treated her and have no first-hand knowledge of her health situation or care. My comments are solely gleaned from watching the documentary, Gaga: Five Foot Two, a few times. My goal is to use my long-standing clinical expertise, including more than 100 peer-reviewed publications and three books on fibromyalgia, to help provide some objective perspective on this subjective endeavor.

Gaga’s Medical Background, Genes, and Aunt Joanne

The background story of Lady Gaga’s deceased aunt, Joanne, as described in the documentary, was fascinating. Joanne died 41 years ago, at age 19, from systemic lupus erythematosus (lupus). From the brief discussion in the film, Joanne’s lupus had not been appropriately treated, and Joanne was told that both of her hands would require amputation, just before she died. Despite never knowing Joanne, Gaga has identified closely with her, especially recently. Lady Gaga dedicated her most recent album, as well as her current world tour, to her Aunt Joanne, and in the film, tells a New York Times reporter, “I am Joanne.” Indeed, Gaga’s full name is Stefani Joanne Angelina Germanotta.

There is a very moving scene in the film when Gaga plays her song titled, “Joanne,” to her grandmother.  Lady Gaga seems to have been touched by Joanne’s illness, as well as that of a woman named Sonja, who is identified in the film as Gaga’s friend, undergoing treatment for cancer. It is possible that Gaga may have wondered whether her own symptoms could be related to lupus or another autoimmune disease. Lupus and fibromyalgia both have significant genetic underpinnings. There is an 8.5 odds ratio of having fibromyalgia in family members compared to the general population.2

There is nothing in the film that suggests to me that Lady Gaga has lupus. Fibromyalgia is not considered to be an autoimmune disease in the classic sense. Nevertheless, fibromyalgia is present in 40% of women with lupus compared to 3% of the general population.3

Lady Gaga performs despite having fibromyalgia, a chronic pain condition. i

The Pain of Fibromyalgia

The film opens with Lady Gaga at her mansion in California, in a happy mood, in her kitchen with her loving dogs. I was immediately struck by the close relationship she displays with her dogs and her staff. From years of working with fibromyalgia patients, I have observed that they function best when surrounded by loving family and friends. Her personal chef is carefully preparing Gaga’s food. It has been well documented that poor eating habits and obesity can aggravate fibromyalgia and chronic pain. In one study, nearly 50% of women with fibromyalgia were obese.4

While Lady Gaga does not struggle with obesity, she does describe in the film her chronic pain and its relationship with her mood. She states in the documentary, “If I get depressed, my body goes into spasm”, describing the spreading pain from her lower extremities to her trunk and up to her face. This spreading pain is characteristic of fibromyalgia.1 Lady Gaga often reports the pain as “spasms” or “pulling and tightness”. She also uses the term “inflammation”.

There are many different descriptions of the quality of fibromyalgia pain in the literature, from “dull and throbbing” to more of an “acute pain with muscle spasms”, Gaga identifies a specific thigh muscle as being particularly troublesome. I have found over the years that patients, like Lady Gaga, who is very athletic or involved in dance or the performing arts tend to describe their pain more anatomically, as one would with an injury.

This characterization also fits with Lady Gaga’s statement in the film that her pain followed her “broken hip”. This could be interpreted in a number of different ways. It is certainly possible that the hip injury she references in the film as occurring three years ago precipitated fibromyalgia. Many patients with fibromyalgia report that physical trauma was the inciting event of their chronic pain.5 The initial, localized pain seems to spread and become chronic and widespread in such situations. However, later in the film, Lady Gaga describes enduring more than five years of physical and mental anguish. It is, therefore, possible that she may have been suffering from long-standing fibromyalgia well before the hip injury.

Either way, it is important for Lady Gaga or any patient with fibromyalgia to understand that muscle inflammation and/or muscle injury are not typically the cause of the pain they feel. Fibromyalgia experts have long dismissed the notion of “fibrositis”, that is, fibrous bands of muscle inflammation, in this disorder. Rather, fibromyalgia is considered to be the prototype of what is called “central sensitization”. This type of pain is largely the result of hyperactivity of pain sensation in the brain and spinal cord.6 Yet, patients and healthcare providers are often caught in the dilemma of treating central or peripheral pain.

Both Lady Gaga’s focus on severe muscle spasms and tightness, as well as the physical nature of her treatment, are common in fibromyalgia but can be somewhat misleading. Throughout the film, Gaga receives deep muscle massage, especially to her neck and shoulders, and physical manipulation. Her fibromyalgia physician is a physical medicine and rehabilitation specialist who is shown performing trigger point injections on Lady Gaga. At another time, Gaga receives an injection in her buttock. Each of her pain flare-ups is treated with her passively receiving deep massage or injections, or what appear to be very appropriate stretching exercises. Yet, there is no mention of specific therapy addressing central pain.

The Pain/Mood Interface

Despite the treatment focus on her hips and neck and shoulder muscles as the believed source of Gaga’s pain, she is well aware of the relationship of her pain with her mood and levels of stress. She has been dealing with what she calls “body pain, fear, paranoia, and anxiety for the past five years”. She surmises that three failed relationships each aggravated her pain and depression.

This experience among the general population has been termed the pain/depression dyad.7 Nearly 50% of patients with fibromyalgia or related chronic pain have co-morbid depression.1, 2, 7 This bidirectional relationship of depression-aggravating pain and vice versa is represented across many chronic pain disorders, including fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic pelvic/bladder pain.

Both physical and emotional stress are known to aggravate fibromyalgia. Analogies have been made to fibromyalgia and post-traumatic stress disorder (PTSD). In a twin study, stress scores were strongly associated with chronic widespread pain.8 In a study of more than 500 subjects, 45% of fibromyalgia patients compared to only 3% of population controls met the criteria for PTSD.9

Gaga’s life as one of the world’s superstars is likely incredibly stressful. In the film, she has an emotional “melt-down” during the preparation for her two biggest performances of 2016-17: playing in front of the Democratic National Convention and singing at the Super Bowl half-time show. During the preparation for these nationally televised performances, she shares an exacerbation of her pain. Following both, the viewer sees Gaga lying in tears, wracked by pain, receiving deep massage and tissue manipulation. Yet, after her performance she is emotionally and physically relieved, noting, “I didn’t feel tight or worried”.

Is There a Fibromyalgia Personality?

Lady Gaga demonstrates in the film some personality traits that are understood to be more common in patients with chronic pain and mood disturbances. She is clearly driven, as is true of many highly successful people. Yet, she describes being insecure: “I was never pretty enough or good enough;” and “what I was on my own wasn’t good enough.” She describes feeling more in control at the present time, able to “put my own spin on it”. However, her insecurity persists, as she comments, “I can never get it all right at the same time”. Greater self-efficacy has been identified as an important personality factor in fibromyalgia.10 Despite her larger-than-life outward facade, Gaga seems to be concerned with her self-image.

The documentary further discusses the radical departure in her persona as well as in her music. She has recently made the choice to perform with less makeup and simpler costumes, for example, and her music has turned from electronic dance pop to include very personal ballads. As a practitioner, I am optimistic that these changes will help Gaga better cope with fibromyalgia as they demonstrate advancing self-efficacy.

Sleep and Pain

One of the initial experiments in fibromyalgia research was performed in a sleep laboratory in Toronto.11 Medical students had their brain-wave activity recorded throughout the night. Whenever their brain wave demonstrated deep, stage-4 sleep, the student was aroused. After a few nights of non-restorative sleep, the students reported chronic pain and fatigue, characteristic of fibromyalgia. Non-restorative sleep is one of the strongest predictors for developing chronic pain.12 It also correlates with mood disturbances.

With late-night shows and concert tours around the globe, it is likely that maintaining a regular sleep cycle is difficult for Lady Gaga. At one point in the documentary, just before the release of her new album, Gaga is asked by one of her staff, “Will you sleep tonight?” She is then handed an unknown pill. At a later period in the film, we see her trying to fall asleep in the cabin of her plane.

Physical Activity and Movement

Cardiovascular exercise, stretching and strengthening are recommended for the treatment of fibromyalgia.13 There are numerous studies of the benefit of exercise for chronic pain, as well as for depression. Throughout the film, we see Gaga performing advanced dance moves that stretch every muscle in her body. I would describe her routine as that of a professional athlete.

Intense exercise has the added benefit of releasing endorphins and other neurotransmitters that can be powerful analgesics. Like the football player who runs for a touchdown on a broken leg, Lady Gaga describes the “adrenalin rush” during her performances as a potent “high”.  

For the vast majority of people with chronic pain, too little exercise and activity is a much greater issue. One potential concern for Lada Gaga, however, may be whether she or other patients are overdoing their exercise routines, injuring themselves and thus aggravating their chronic pain. Lady Gaga’s reported hip injury could have been the result of pushing herself to limits that her body could not safely endure.

As a general guide, most athletes know how far to push themselves, but guidance from professionals such as athletic trainers and physical therapists can be helpful. Balancing quick bursts of exercise, such as Gaga’s dance workouts, with more gentle exercise, such as swimming, might be useful. As noted, in the documentary, Lady Gaga consults with a physical medicine and rehabilitation specialist.

Gaga admits in the film to being worried about potential pregnancy in the future and “what would my hips do” during childbirth. There is no evidence that fibromyalgia is associated with pregnancy risk or increased childbirth abnormalities. In the thousands of women who I have treated with fibromyalgia, some noted an exacerbation of pain during pregnancy whereas others noted less pain.

Treating with a Team-Based Approach

Optimal management of fibromyalgia, in addition to exercise, includes medications and what might be called a balanced “mind and body” program.1,6 There are three FDA-approved drugs for fibromyalgia: pregabalin, duloxetine, and milnacipran. Low doses of tricyclic compounds, such as amitriptyline at bedtime, can be effective. Unfortunately, many patients do not have sustained relief of their symptoms or cannot tolerate the side effects from these medications.1,6 Often, combinations of these medications at doses considered to be suboptimal perform better then pushing a single drug to the maximum recommended dose.

Medications are not discussed in detail in the Gaga film. It is noted in the film that she is taking Mobic twice daily. Mobic is a non-steroidal anti-inflammatory drug (NSAID), like a high dose of ibuprofen. Although NSAIDs are commonly prescribed in fibromyalgia, there is no current literature noting their effectiveness.

Lady Gaga describes in the film her past use of drugs and alcohol. It is not clear whether the usage represented a lifestyle choice or a way to help manage her pain. Research demonstrates that opioids are ineffective in chronic pain disorders, such as fibromyalgia, and some researchers believe that chronic opioid use leads to a worse outcome in fibromyalgia.1,6

As noted above, Gaga’s treatment during the film seems focused on the body aspects of a balanced mind and body program. It is very appropriate in my opinion that she is utilizing techniques such as deep massage, stretching, and trigger-point injections, although there is limited evidence for their efficacy in fibromyalgia.1,6 Nevertheless, I encourage fibromyalgia patients to utilize any non-pharmacologic therapy that seems reasonable. For example, there is sound evidence for the efficacy of Tai-chi in fibromyalgia.14 Her specialist is shown in the film focusing on such “physical” procedures. However, at one point, this provider does tell Gaga that a mental health professional will later focus on the “mental pain” she is suffering.

Lady Gaga, therefore, seems to be under the care of an expert team, with experience and expertise in chronic physical and mental pain. Education and learning strategies, often termed cognitive behavioral therapy, to cope with chronic pain, not necessarily curing it, is key to successful multidisciplinary therapy.15, 16 No single healthcare professional can adequately address all aspects of chronic pain and team care is the best way to accomplish this based on my experience.

To Diagnosis, or Not?

Although Lady Gaga does not state that she has been given a fibromyalgia diagnosis in the film, she tweeted, as noted, in September 2017 (the same month the documentary was released) that she has fibromyalgia. As with many patients, the diagnosis can be elusive. Gaga complains that “I have chased this pain for the past 5 years”. Indeed, the average patient spends about 5 years before a diagnosis is made.1

She also astutely worries that the average person must find getting a timely diagnosis and optimal treatment even more frustrating. Many physicians still believe that labeling a person with the diagnosis of fibromyalgia “medicalizes” every-day subjective symptoms and amplifies “sickness behavior”.17

However, numerous studies have demonstrated that a fibromyalgia diagnosis, along with detailed patient information, is enabling not disabling.18 Finding healthcare providers who are willing and able to treat fibromyalgia is very challenging. The healthcare team that Lady Gaga has may be financially out of the reach of most people, as she alludes to herself in the film. Many of the treatments that she seems to be receiving, including injections of platelet-rich plasma, are not covered by average healthcare insurance.

Continue Reading:
A Fresh Look at Opioid Antagonists in Chronic Pain Management

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