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Demystifying Chronic Pain, Fibromyalgia, Rheumatic Disease and Long Covid:
Podcast, Provider Interviews

Demystifying Chronic Pain, Fibromyalgia, Rheumatic Disease and Long Covid

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Video of conversation:

Episode Summary:

Christine Stamatos is a nurse practitioner who specializes in non pharmacological methods to manage chronic pain, fibromyalgia, rheumatic disease and long COVID.  In this conversation she provides a comprehensive overview of different types of pain and explains how they overlap in these conditions.

Christine highlights the importance of lifestyle methods to manage chronic pain including sleep hygiene, stress management, anti inflammatory nutrition, exercise and more. She gives specific tips for how to live with fibromyalgia. Cheryl and Christine also discuss the importance of focusing on what brings joy and meaning to one’s life while managing chronic illness.

Overall, the conversation underscores the importance of a comprehensive approach to chronic pain management that addresses both the physical and emotional aspects of the patient’s well-being.

Episode at a glance:

  • Chronic pain explained: Christine explains the 3 types of pain: nociceptive (as seen in active inflammation / tissue damage in RA), nociplastic (central sensitization, as in fibromyalgia) and neuropathic pain (nerve pain). She gives tips for how to live with fibromyalgia, rheumatic disease, and/or long covid.
  • Lifestyle: They discuss the best lifestyle adjustments to manage rheumatic disease, fibromyalgia and long covid, including sleep, stress management, exercise, nutrition and more
  • Mental health: The significance of addressing both the physical and emotional aspects of a patient’s well-being in chronic pain management.
  • Acceptance: Utilizing Acceptance and Commitment Therapy (ACT) as a valuable tool for managing chronic pain and navigating uncertainty.
  • Joy: Focusing on finding joy and meaning in life while accepting the changes that come with chronic illness.
  • Patient-provider relationship: Tips for building a trusting relationship with your health provider
  • Long Covid and Fibromyalgia tips: Christine shares her best tips from her long covid and fibromyalgia clinic

Medical disclaimer: 

All content found on Arthritis Life public channels was created for generalized informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Episode Sponsors

Rheum to THRIVE, an online course and support program Cheryl created to help people with rheumatic disease go from overwhelmed, confused and alone to confident, supported and connected. See all the details and join the program or waitlist now! 

Speaker Bios:

Christine Stamatos DNP, ANP-C, Leadership Role: Past President (2020-2021), Association of Rheumatology Professionals (ARP), Affiliation: Northwell Health, Division of Rheumatology, Director of Fibromyalgia Long Covid Clinic, Assistant Professor, Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies

Christine A. Stamatos DNP, ANP-C is an Adult Nurse Practitioner (NP) working in Rheumatology since 2002. In 2012, Christine returned to Stony Brook University School of Nursing to complete a Doctor of Nursing Practice degree with research focused on physical and cognitive behavioral strategies for chronic pain in patients with rheumatic disease (RMD). Her current practice is uniquely situated between both a private and academic practice within the Northwell Health system, in the Division of Rheumatology.

She is currently the creator and Director of the Fibromyalgia Long Covid Clinic for Northwell Health. This program is designed to address the biopsychosocial needs of patients living with chronic widespread pain, fatigue, dyscognition and associated mood disorders through evaluation, education, coordination, treatment and social support. 

The focus of Dr. Stamatos’ scholarship includes patient wellbeing and interprofessional education, practice, and community engagement. Dr. Stamatos disseminates her work through peer-reviewed publications, professional and scientific presentations. In addition to patients with Fibromyalgia and Long Covid, Christine has a full complement of patients with a variety of RMDs and she brings the focus of wellness to all patient encounters.

As an active member of the American College of Rheumatology (ACR) she has been involved in ongoing education and training of the interprofessional team through her work over the years as an active member of the ACR Committee on Workforce and Training, Student and Resident subcommittee, the NP-PA Fellowship in Rheumatology Task Force, and The Annual Planning Committee, eventually serving as the chair of this committee. Christine is currently a Past President of the Association of Rheumatology Professionals (ARP), a Division of the American College of Rheumatology. Serving in executive leadership, Christine represented her fellow members on both the ACR and ARP Executive Committees, and Rheumatology Research Foundation Board of Directors. She continues to serve in leadership throughout these divisions with an aim of improving access to quality care for patients living with RMDs.

Christine has a strong commitment to education and service. In pursuit of these goals she conducts monthly education seminars for the community and has been an active member of the American Red Cross serving in both Super Storm Sandy and Hurricane Katrina. Additionally, she regularly volunteers with medical missions. In association with Blanca’s House, she has created a standing Continuity Clinic in Rheumatology to advance access to rheumatology in underserved areas across Central and South America.

Cheryl Crow

Cheryl is an occupational therapist who has lived with rheumatoid arthritis for nineteen years. Her life passion is helping others with rheumatoid arthritis figure out how to live a full life despite arthritis, by developing tools to navigate physical, emotional and social challenges. She formed the educational company Arthritis Life in 2019 after seeing a huge need for more engaging, accessible, and (dare I say) FUN patient education and self-management resources.

Full Episode Transcript:

Cheryl:  00:00

Okay, I’m so excited today to have a fellow multi-passionate person. I mean, a lot of people we’ve had in the podcast are multi-passionate, but we have someone that I really look up to in the rheumatology community, Christine Stamatos. She is going to tell us a little about herself. But she is somebody who’s done a lot of amazing work in the Association of Rheumatology professionals, and which is like the sister org to the American College of Rheumatology. So, why don’t you give us a quick introduction to you and your work? And what is, yeah, what is your relationship to arthritis?

Christine:  00:37

So, that’s a great question. So, I’m a nurse practitioner by trade. I worked as a critical care nurse for 20 years and then went back to get my NP certification. And then, while I was in school, I met someone who was a rheumatologist and I thought I was just gonna go and do a little bit of time with the rheumatologist. I spent one day and knew that was what I was going to do the rest of my life. He was amazing. So, I then switched over when I graduated and went into rheumatology. I worked in rheumatology for many years under some amazing rheumatologists who taught me so much in some of my mantras — you asked me if I had mantras — some of my mantras come directly from those people. I then was working in a practice with I think there were four other providers. So, four physicians. I think there was a one physician assistant. 

And in all of this, so this was the third practice I was in. And in every practice I went to, I always ended up with the patients who had a lot of questions, who started crying in the visit, who had issues with compliance. Everyone would say, “You know, I think you should follow up with Christine.” So, they would end up on my schedule. And I don’t, I think that has to do with the fact that I’m a nurse practitioner, and we look at patients on a more holistic and biopsychosocial approach. So, anyway, I started seeing patients that had really just severe pain, and they’ve been to, you know, multiple pain providers, neurologists, orthopedist, surgeons, and they were, they were stuck. Nobody had any answers for them. 

And so, it drove me actually to go back to graduate school. And I went back and got a doctorate. And my focus on my doctoral work was on non-pharmacologic strategies for chronic pain. So, now my practice is taking all of those years of experience in rheumatology and then, specifically with pain, and applying them to people who live with rheumatic disease, which, as you may or may not know, is something that, you know, many people live with. So, when it comes to arthritis, I do not carry a specific diagnosis of an autoimmune inflammatory arthritis. I, of course, have osteoarthritis because I’m 62 years old, and that’s what happens when you get older. And I do suffer from very severe osteoporosis. And so, I can understand, and I’ve had multiple fractures as a result of it. So, I do understand what it is like to live with a chronic condition. But my lot in life is to help people to live with their condition and live the fullest and best life possible.

Cheryl:  03:12

That’s amazing. I’m sorry, I didn’t know you — I thought you were, like, 49. Like, literally, so I’m just gonna — I’m like, yeah, that’s amazing. You’re amazing. And, yeah. 

Christine: 03:22

Thank you. 

Cheryl:  03:23
Yeah. And I want to take a second to read, for people who haven’t listened to the previous episode with a nurse practitioner, Kori Dewing, can you just explain a little bit the role of a nurse practitioner in rheumatology? 

Christine:  03:38

Yeah, absolutely. I think that’s a great question. And I’m gonna say that nurse practitioners and physician’s assistants in the field of rheumatology are very similar. So, you’re really not going to be, as a patient, you’re not going to see a difference. It’s just how we got to that role that makes a difference. So, physician assistants, I don’t want to speak for them. I’m not a physician assistant, but generally speaking, they too get at least a master’s degree. It’s a post-graduate after a, you know, a bachelor’s program. They have a two-year program that is very much rooted in medicine. And their whole curriculum is designed very similarly to a lot of physicians’ education is designed. And nurse practitioners go through, all nurse practitioners also have a master’s and now some of most of the programs are actually producing doctoral degrees. So, you have the difference is that nurse practitioners, you have to be a nurse first. So, you have to have worked in nursing for the most part. That is not always the case anymore. Sometimes people are going all the way through school through a DNP program and never really actually worked on the floor. 

So, but again, the difference is more that PA’s with that medical model come at patients with a medical perspective. Okay, here’s the diseases, here’s what we need to treat; whereas nurse practitioners and nurses come from the perspective of here are your symptoms and what do we need to do to make them better? If that means we recognize that you have a disease and we treat the disease, that’s absolutely part of it. But we can also then recognize that maybe you have a sleep issue, maybe you have huge stressors at home, maybe there are some significant social determinants of health that are impacting your ability to get the care that you need, so you’re not getting it. So, I can say, “This is what you have,” I can say, “This is what you need to do,” but that doesn’t necessarily happen. And I think everyone in medicine is more focused on a shared decision-making process. I like to think that nurse practitioners excel at that. 

Cheryl:  05:35

Oh, that’s such a beautiful way to put it. So, just acronym alert as we go through this episode. Yeah, when you hear NP, that’s nurse practitioner; when you hear PA, that’s physician assistant. But one of the other things I would just quickly add, because people might be confused if they go to a rheumatology clinic and they think, “Well, the only person here who is authorized to prescribe medications or, you know, be my main treatment plan coordinator is the rheumatologist,” which is an MD medical doctor. But no, at least I know, I’m in Washington State. So, I know in our state NP’s have almost all — not exactly all the same — but a lot of the same powers of prescribing and stuff and such. So, that’s, yeah.

Christine:  06:19

Yeah, a hundred percent, you’re absolutely correct. And I should have mentioned that I was sort of talking about preparation. But yes, so how nurse practitioners and physician assistants are utilized in each practice will vary across the country, across the different states. But I’m in New York, and like you said, in Washington, I have full prescribing privileges. There are no restrictions whatsoever on what I can do. I would say that as you’re out there, and you’re a person just may be coming into the field of rheumatology and you don’t know who should be taking care of you, nurse practitioners and physician assistants in many places do carry their own panel. 

What you’re looking for is some experience. So, because we didn’t go to medical school, we do need to be experienced. I will tell you that for the first seven years of my practice, I didn’t see one patient without also having them see the physician. Now I’m 20 years in practice, and I actually have my own panel. And, you know, I bring the physicians in when I feel like I don’t know how to handle a situation. Or if a patient says, “Can we have the physician come in,” but for the most part, for the most practices, it’s a team approach. So, oftentimes, the NP or the PA, the PA will go in and evaluate and talk to you, get the history, and then bring the physician in, “Okay, this is what my thoughts are, this is what I’m thinking of doing. Let’s make a plan together.” And then, together you monitor over time. 

Cheryl:  07:39

Yeah, that’s wonderful. And I really do think with a chronic condition like rheumatoid arthritis, psoriatic, you know, where you’re going to be living with this 24/7, right, the lifestyle variables, like you said, looking at sleep, stress management, non-pharmacological, you know, tools and tips. I mean, I guess, as an occupational therapist, that’s also all that — we don’t do any prescribing or any, you know, so we are very passionate about that aspect, too. So, I definitely want to use our time partly to talk about, you know, your research and what you found are some of the best non-pharmacological pain management tools. It’s hard to, I think you said earlier, you specialize in chronic pain in your research, and in rheumatic disease, which I think I’m going to preface — sorry, this is how I my brain works, I just have to think through my thoughts out loud, even though we already made this organized document of the questions. But before we go into the actual techniques, can you explain the difference between chronic pain that is from like an injury that then became a chronic pain versus a chronic ongoing condition like rheumatoid arthritis? Do you know what I’m saying? 

Christine:  08:51

Yeah, so I would say one of the biggest jobs that I do in terms of working with patients and teaching patients is, especially with a chronic rheumatic disease, is to help them understand what is chronic pain from the fact that you’ve had chronic pain for a lot of years, and what is chronic pain that’s inflammatory that requires me to change your inflammatory treatment. I had a patient recently referred to me from one of the other rheumatologists in my practice, and she, the patient had a history of psoriatic arthritis, but also had chronic widespread pain for many, many years. So, she was sent to me for her chronic widespread pain. 

And I evaluated her and her psoriasis was out of control. Head to toe, her body surface area was more than 60%, 70% covered, and she had active joint inflammation. And when I sent her back to the person who sent her to me, you know, I said, “Well, the first thing we have to do is we have to change her therapy because she’s not under control. And I can’t treat the chronic pain condition if there’s an underlying inflammatory condition that is not under control.” And so, it’s all about learning what to look for, and I think that, I’m not sure how much of your your community knows about the different inflammatory markers that we look at. So, there are —

Cheryl:  10:06

But first, sorry, just really quick, when you said the therapy, you are talking about medications, right, the medications?

Christine:  10:12

In her case, I had to get her inflammatory condition under control before I can start treating the other conditions. So, I have a few rules when it comes to chronic pain. And that is that you can’t, you cannot treat chronic pain if you have ongoing inflammation, if you have a sleep disorder, and if you have a mood disorder that’s not addressed, and/or any other major stressor. So, if those things are not addressed, there is nothing that you can do to treat someone’s pain. And so, trying to treat that pain with like a pain medicine while you haven’t treated those other problems is only going to cause more problems. And that is what we saw in this this last decade with the opioid use and abuse that happened. 

Cheryl:  10:58

Yeah, yeah. And so, when we say, you know, I think this is a really common area of confusion with the phrase ‘chronic pain’ because you’re like, okay, I have a chronic disease called rheumatoid arthritis, and I have pain, then therefore, I have chronic pain. But normally, in the research, you’re actually when we say the word ‘chronic pain’, providers are usually talking about that central sensitization, right? Or how would you describe it?

Christine:  11:26

I mean, the term chronic pain is exactly what you say, it’s just pain that lasts more than three months. 

Cheryl:  11:33

Yeah, not very specific. 

Christine:  11:36

It’s not very specific. What you just said is you said a specific type of pain and that is centralized pain. There are three different major types of pain. There’s centralized pain, is the one where the brain is processing pain incorrectly. It perceives things as painful that should not be painful. And then, there is tissue-related pain, which is, you know, you have an inflamed joint, you have a broken bone. That is actually, there’s a — I’m blanking on the name for it. And I’m sorry that I’m blanking on the name, give me two seconds so I don’t give you the wrong name. I just, it’s funny. I just had this up because I wanted to make, I wanted to make sure I didn’t — okay, so there’s, that’s called in the medicine world, we call that nociceptive pain. Right. So, that’s, that’s the kind of pain from an injury from inflammation. Then we have another, the third kind of pain is neuropathic pain. And neuropathic pain is nerves that are bothered. 

So, carpal tunnel syndrome causes neuropathic pain. Diabetes that causes peripheral neuropathy, that’s neuropathic pain. So, I don’t know your story. I know you have rheumatoid arthritis; I’ve seen you wear a lot of braces. I’m guessing there’s a good chance you might have some carpal tunnel. So, you just told me that there’s the possibility that you could have nociceptive pain, neuropathic pain, and you’ve had pain for a long time that maybe hasn’t always been treated. So, you might also have an element of centralized pain. So, in any one person, you can have all three types of pain. In most people that live with a chronic condition, there are all three types of pain. 

Cheryl:  13:13

And that’s, I think, you first of all, thank you for providing that overview. And I think it’s when you can’t see the tissue damage cause it’s so far into your joint, right? Well, like with rheumatoid arthritis and I’m say that if I’m having a joint flare up, it feels like someone’s squeezing my hand from the inside out, you know. Not from outside, because you could feel from deep within. It’s hard to know, is this central sensitization in the sense of my brain has become oversensitive to the perception of pain in my joint, and there’s a small amount of stimulus that’s evoking a gigantic response and it’s actually the tissues are fine, or are the tissues not fine? How do I know? 

Christine:  13:13

Yes. So, that is the grand blue hot question. That’s the question we’re always trying to figure out at every single visit that I have with a patient, that’s what we’re trying to figure out. But there are objective ways. So, let me just talk a little bit about some of the objective ways to look for it, for the pain. So, again, I mentioned lab, right? So, there’s some bloodwork. There’s something called a sedimentation rate, the ESR. This is something that we measure in almost all RA patients and almost all patients with rheumatic disease. So, that’s one thing and that should be generally between 20 — I don’t think I need to give you the numbers, but if you want me see if I can. It should be between 20 and 30 or less, which that’s a good sign to be in to, right? That means you’re, there’s not a lot of systemic inflammation, but that’s only one way to look for inflammation. 

We also can use something called the C-reactive protein. And that is one of the drivers, actually, that’s associated with the inflammation we see with cardiovascular risk and rheumatic disease. So, when that number is persistently elevated, and again, that number we always worry about when that number is well over 10 or 20, okay. And really, if I told you that patients who have acute COVID that were really, really sick, their C-reactive protein numbers were 300 and something. So, the range is pretty massive. So, you really have to have double digit numbers for it to be of a concern. Some other things that can tell us if there’s inflammation in the body, you look at your CBC. So, you don’t need those fancy tests, you can just look at your blood count.

Then you look at are you anemic? Sometimes when the body is really inflamed, it’s very hard for the body to, there’s so much work that the bone marrow is doing to make all the inflammatory cells that is not making enough of the, or it doesn’t have the ability to make enough red blood cells. So, you ended up with anemia. It’s called anemia of chronic disease. So, we look at the blood count. And then, we also look at our platelet count. When the body is terribly inflamed persistently and not controlled, the platelet count actually goes up. And it goes into the 400 or 500 range. And anything above that is like really severe inflammation. 

So, those are some. There’s some other tools, but those are the big ones that we look at. Those are lab tests that we can do. Most rheumatic diseases don’t usually affect the white blood cell count. Lupus can cause your white blood count to go down, doesn’t usually cause it to go up. And then, infections usually cause the white count to go up. There are also some drugs that can cause some drugs, and specifically the IL-6 inhibitors are known to cause a decrease in white blood cell count and specifically neutrophil count. 

So, those are the labs that we look at. And then, if we’re really still not sure, there’s imaging that can be done. And the most effective and least expensive imaging is to do ultrasounds, and many clinics have ultrasounds right in the clinic. And you can come in and say, “Christine, I really feel like my fingers swelling,” and I look at your finger, and I don’t see anything. So, I can say, you know, “Let’s do a scan and let’s see.” And then, if we see nothing, then yes, there’s probably an element of centralized pain. If we see inflammation, then no, you probably have active inflammation that we haven’t controlled fully.

Cheryl:  16:58

Yeah, that’s so, so helpful. So, basically, if you, concurrently, if I want to, if I summarize this, concurrently, if you have a rheumatic disease like psoriatic arthritis or RA, and you’re having pain in the joints, and but you’re not sure how much of it is from inflammation and maybe is sometimes if you have a lot of inflammation, it’s a sign that maybe you need to change your medication regimen and stuff. But you start off it like what objective measures can we get to help us figure out. Yeah, we measure the inflammation through the bloodwork and the ultrasound or other imaging and then it’s really like a choose-your-own-adventure. Like, if this, then this.

Christine:  17:37

It is completely.

Cheryl:  17:38

Yeah, I know that some of these things are listed out in like the textbooks and stuff, you know. And then, you say, okay, if you’re still really having this persistent feeling of pain even though we’re seeing all of your inflammation markers are low, and it doesn’t mean that your pain is not real, it —

Christine:  17:54

A hundred percent does not mean that your pain is not real. So, now we need to just think about okay, so what else are we missing, right? So, if that was if you were in my office, and I got to that point, and I’d say, okay, so I really think that what’s going on is that you’ve had chronic pain for so long, you do have an element of centralized pain. And they’ve now got a bunch of different words for that. The other word that are using nowadays is ‘nociplastic pain’, your scientific word for that. But anyway, and then it has a totally different treatment regimen. 

So, for each of those three different types of pain, if you talk to me, and you say that your pain is more burning and radiating, that sounds more nerve-like, so I’m going to use medicines that treat nerve pain. If you say it’s more diffuse and all over the place, and it hurts for people to hug me, for my child to, you know, to play with me is too painful, that I think of is more of that centralized pain, and there’s a different treatment regimen for that kind of pain.

Cheryl:  18:49

Yeah, so I think let’s dive into those. I mean, if that’s okay, like what, you know, because I’m really glad we took a minute, two or three minutes to go over the different kinds of pain because that question is the foundation for the next question I was going to jump to which is, what are the pain management techniques? So, you want to use the right tool for the right, like you were just describing. 

Christine:  19:11

Exactly, exactly. And it’s often different from time-to-time, from visit-to-visit. And that’s I think what you and your relationship with whoever your provider is needs to understand that you’re on a journey together. This is a marathon; it is not a sprint. There are not quick fixes and we need to be patient, right. So, one of the things that happens if you’re someone who has gone on to develop some centralized pain, and I will tell you that the rate of people with chronic rheumatic disease and centralized pain is very high. So, for example, the epidemiology says that for Sjögren’s disease for example, 30% to 40% of the patients also have centralized pain. For rheumatoid arthritis. It’s anywhere from 25% to 35% of people. For ankylosing spondylitis, it’s even higher. And I think it’s because of the delay in diagnosis. For lupus, it’s also around 30% to 40%. So, if you’re lucky enough to not have that, you don’t have to worry about it at all. I’m gonna get off on that tangent, there was something else.

Cheryl:  20:10

Oh, we’re talking about treating the right kind of pain management techniques for the right, matching the right technique to —

Christine:  20:17

Oh, I know what I was going to say. 

Cheryl:  20:18

Yeah.

Christine:  20:19

So, if your provider hasn’t recognized that there’s a centralized component, what I see happen oftentimes is people are jumped from one biologic to another to another to another. So, I know there’s been some disconnect when I see someone who’s been through, you know, seven different biologic agents. That shouldn’t happen. I very infrequently will change an agent, because to me, you want to prove to me that it’s inflammatory, otherwise, I’m going to try other things. And I think that’s better for the person, because then when you do really truly have a flare, there’s still 15 things that you can go to. Whereas if I barreled through all of the other options, then you have a flare, we’re stuck with, “Oh, my God, she’s tried everything and nothing’s working.” And that’s never the case. 

Cheryl:  21:02

That’s a, yeah, that’s a tricky one. Because I mean, again, being an occupational therapist is medications are beyond my scope, but I look into it so I can be more informed. And it does seem that there you know, that there are people who have like that treatment resistant, you know, RA where they might have to — sorry, I don’t want to go on that tangent too much. But there’s some, I have seen some patients in my support groups where it’s like, they tried the TNF inhibitors. I tried, like the IL-6 inhibitors, and then all of a sudden they try the JAK inhibitors and it was like jackpot, like they sometimes you do, right, have — I mean, you know, just —

Christine:  21:38

Yes, yes. So, you know, we’re hoping one day to have precision medicine, right, that we’ll be able to genetically determine this is the kind of treatment you’re gonna need. You’re an RA patient, you’re gonna respond to TNF inhibitors, you’re gonna respond to JAK inhibitors, you’re going to respond to IL-6 inhibitors. Everyone is different. And unfortunately, it’s a crapshoot right now, right? We have to try one thing. And then, and we’re dictated oftentimes, that trial, that order of what we’re going to use, is based on what insurance companies say. I love it when a patient comes in, and they say that my brother or my mother has got rheumatoid arthritis and they’re doing great on this drug, because that tells me that this person probably will also do pretty well. The other thing is understanding as providers, we need to understand primary and secondary failure. Have you ever heard that expression?

Cheryl:  22:24

I’ve heard but I can’t remember what it means.

Christine:  22:27

So, primary failure is if I put you on a drug, and it’s in a certain category, and in the first three months, you had absolutely no reaction, just didn’t do anything for you. This was not a drug that your body responded to. That would be considered a primary failure. But if I put you want to drug and you did great for a year. 

Cheryl:  22:45

Oh, that’s what I’ve had. Yeah. And then — okay.

Christine:  22:47 

So, that’s a secondary failure. And so, what the recommendation is, is to stay within that class if you’ve had a secondary failure. So, if I started doing a TNF, and you did great, but you stop, it stopped working for you after a year or two, you should at least stay within that that category for another time or two and see what happens. Now if the time that you stay in remission is shorter and shorter, it’s clearly time to move on, right? But if you never had a response, you shouldn’t stay within that.

Cheryl:  23:15

That makes — I actually just followed, I followed that textbook because — or my rheumatologist must have because, yeah, I started on Enbrel, and then my body developed antibodies to Enbrel, so then I went to Remicade. Both of those are the TNF inhibitors. And it wasn’t — Remicade work great until after my pregnancy, and my, you know, your immune system can kind of get wackadoodle after that. Anyway, that’s a long other story, because at the time, the recommendation was to go off the Remicade during the last trimester because that’s what they thought, that was 2013, 2014 but now they, you stay on it. 

But anyway, you know, so, if we go back a second and think, okay, so, if you have rheumatoid arthritis, which most people listening have something similar, whether it’s, you know, ankylosing spondylitis —

Christine:  23:59

Psoriatic arthritis. 

Cheryl:  24:00

Yep. So, it seems like the first line of defense is get that under control as much as you can. And then, if you’re like, wow, like, all of your inflammation markers are really good. And I don’t see any signs on your ultrasound of inflammation, then let’s — I’ve seen so many patients who say, “My doctor said, Well, I can’t do anything for you, because I don’t see any active signs of inflammation,” but the patient’s like, well, right, I can’t function in life right now because I have so much pain. So, you’re like, okay, this is where, in your mind, you know, talking to you Dr. Stamatos, it’s like, you know, that okay, this is just another step in this process of determining you still have pain, this is limiting your ability to function in life. This is maybe the nociplastic or a central sensitization kind of pain. Now, let’s talk about the treatments for that, you know, so. 

Christine:  24:52

Right, right, right. Can I go back to inflammatory really quickly?

Cheryl:  24:57

Yes, yes. This is our time, we get to do whatever we want.

Christine:  24:59

One of the one of the other signs of the difference between an inflammatory and a non-inflammatory pain is range of motion. So, typically —

Cheryl:  25:08

I should know this as an OT.

Christine:  25:10

Yeah, you should. Typically, when you’re actively inflamed, there’s a limited range of motion. And I’m using that differently than the word ‘stiffness’ because people who have chronic widespread centralized pain describe stiffness all day long. So, you really can’t use that word. So, even though that’s typically when we teach people, when I teach providers how to recognize inflammatory versus non-inflammatory pain, I teach them listen, if there’s stiffness that lasts more than 15-to 30-minutes, that’s not normal, that’s inflammatory, you know, you need to get to the root of where that inflammation is coming from. But from a patient perspective, I think I would focus more on range of motion. So, when your RA, for example, is really active, you can’t raise your arms, or you can’t make a fist, but one that gets under control, and it’s a centralized pain, you should still be able to raise your arm and make a fist. It may hurt to do it, it may feel stiff to do it, but you should be able to do it. 

Cheryl:  26:04

And if it were active range of motion, not passive. Because in OT, we sometimes do passive range of motion where can someone move your joint through. But no, in the rheumatology, we’re talking about active, if the patientcan do it themselves.

Christine:  26:17

I am, but you’re absolutely right, right. So, there are still some, some centralized pain states where people think they can’t move, and I can use them very easily. So, then that is also is a measure of lots inflammation.

Cheryl:  26:34

And that, but it also could be muscle weakness. And it could be in any, like, that’s a weakness, is it from under use, because you’re in pain and you’re not moving? And so, it’s just so complex.

Christine:  26:43

I appreciate that you said that, because deconditioning is one of the biggest problems that we have, right? When and here’s another statement, you asked me about mantras earlier, one of my mantras is I talk to people about pain. And pain is supposed to tell you that a problem is happening in the body. And we’re supposed to then stop what we’re doing so that we don’t make the pain worse. That’s true in an acute nociceptive pain state, an acute tissue painful state.

Cheryl:  27:13

Tissue is hurt. Yeah.

Christine:  27:15

Issue is injured, tissue is bothered. There’s something wrong with it. But when there’s no tissue injury, that is not the case. And what happens is people do less and less, and then they’re less able to do as much. And then, when they start to be active, everything hurts. So, then they say, “Well, you told me I had to exercise and I went out and then I couldn’t do anything for three days,” well, then you started exercising incorrectly. And we can talk about that later. But so, I’m gonna go back to my word range of motion. Because I really do think range of motion, whether it’s active or passive does help us differentiate from active tissue damage versus no tissue damage.

Cheryl:  27:51

That’s super helpful. And this is, I’m sorry, I’m gonna go on a related tangent to range of motion. But I really wish that I had been referred when I was first diagnosed to a certified hand therapist, which is like an occupational therapist or physical therapist, they have — and so, I’m an occupational therapist, but I did not do the additional 5000 hours and board exam to become what we’ll just call the CHT, a certified hand therapist. But I can, like, as an OT, we are at our baseline, you know, can help treat disorders of the hand. But long story short, we have all these little tiny, like, literally they look — they’re called goniometers, or they look like little tiny, those math tools, you know, that you use. Like the, I don’t know what do they call it, like the thing that you make a circle with in math. Anyway, point being —

Christine:  28:39

A compass?

Cheryl:  28:40

Yeah, the compass. Like, anyway, I have literally, it’s hilarious. My son and his friends, like, take it because they think it’s fun. Like, they like — 

Christine:  28:47

Oh, it is a goniometer. It measures how much you can do. 

Cheryl:  28:50

Yeah, and they, and what would be, what I wish I had been able to do that at the very beginning to get a baseline. So, at your diagnosis, what is your active and passive range of motion? And then, you could see like I have slight deformities in knuckles. Not that bad given that it’s been 21 years since my diagnosis, right? But it’s so, it would be so helpful to be able to track and monitor that over time. Because the problem is when you wait till things are really bad to get that evaluation referral, then you’re like, well, I don’t even know what is your baseline supposed to be right? Because Is this just the progression of your disease? But so, okay. So, if I could say it in like caveman terms, like central sensitization means no tissue injury, right. It means that your brain is very much really having a real signal to your brain that there is pain. I remember I had Dr. Afton Hassett, from her clinic on the podcast in Michigan, and talked about how they do brain scans of people with like fibromyalgia and, you know, you have a clinic with that does fibromyalgia and long COVID. But is that correct?

Christine:  30:02

Can I talk about that? So, let’s talk a little bit about that. So, through the work of places like University of Michigan, between the brain scans which are amazing, they actually show that parts of the brain light up in a more exaggerated way in somebody with centralized pain than someone who doesn’t have it. But it’s more detailed than that. They actually also looked at the messages going up to the brain and the neurotransmitters responsible for communicating that pain. And they measured spinal fluid. And in the spinal fluid of people with chronic pain, fibromyalgia specifically, they found that they created more than three times the amount of something called Substance P. And Substance P is the chemical neurotransmitter that sends a message to the brain that there’s pain here. And so, people with fibro have more Substance P. 

They also have higher levels of glutamate, which is an irritable neurotransmitter that turns all these nerves on and gets everything all excited. And they have high levels of — and this is the reason, I’ll tell you in a second — high levels of endorphins. So, why do you think there’s high levels of endorphins? While the body says, “Hey, there’s a lot of pain here. So, let me give you the endorphin that you need to give you relief,” right? The problem is, the body creates so much of it that there aren’t enough receptors for that endorphin to act on. And so, you end up with the problems, the side effects from it without the benefit of getting the pain relief. So, that’s part of the broken system in centralized pain. 

And it’s also part of why people with centralized pain should avoid opioids. Because what we found is that these people, when you have this kind of centralized pain, we’re just feeding more endorphins into that because an opioid is an exogenous or an outside form of an intense internal endorphin. So, you end up with these high levels of endorphins, exogenously or endogenously. And you don’t get the pain relief. Instead you get the fatigue, you get the dyscognition, you get the constipation. You get the, you know, the lack of energy, all of that is what you get without necessarily pain relief. And we thought there was no ceiling. So, for years in the 1990s, we were taught just keep giving people more pain medicine, they just need more pain medicine. And we were actually making the situation far worse.

Cheryl:  32:28

Oh, my gosh, we should do a separate episode on like demystifying opioids, because it’s definitely. 

Christine:  32:34

You should because I came across a statistic last week, let’s see if I can get this right. More people died in one day from opioid related disease, or use disorders, the way you’re supposed to say it, now than in the entire year in the 1990s. 

Cheryl:  32:53

Wow. And it’s not — and I always feel defensive for chronic pain patients, because I want it to be known that it’s not the chronic pain patients that cause this epidemic. It’s not, it’s definitely not. And there are people who can are very responsible opioid users, but I’m going to refrain from getting on that. 

Christine:  33:15

No, but that goes back to identifying the reason for your pain, right. So, if I treat a nociceptive, if I treat a tissue injury pain, with the right medicine, I get the right pain relief. If I try that same treatment for centralized pain, I won’t get the right pain relief. If your pain is nerve pain, and I throw an opioid at it, it’s not going to work as well. So, when I have someone come in with an acute herniated disc, and they’ve got pain running down their leg, that sciatica that people talk about, right? If I give that person an opioid, it’s not going to work as well. What I need to give that person is something to calm that nerve down. I need to reduce the inflammation of that nerve. So, I usually use something like a steroid and or an anti-inflammatory, and then I need to give something to calm the nerve itself down. 

Cheryl:  34:05

Right. Well and that, I mean, already this is this has been so helpful, but I want to zoom into the methods, non-pharmacologic methods, for managing rheumatoid arthritis, not just the pain itself, but actually like the inflammation in general and just things that we can do and our lifestyle things. Yeah, that and I just have to — where I’m about to put out an episode from our friend, the physical therapy based episode on the 2022 ACR American College of Rheumatology Guidelines for Integrative Treatments including exercise, but Kimberly, but what do you think of when you, what do you talk with your patients about when it comes to these non-pharmacologic —?

Christine:  34:51

So, my very first approach, again, I mentioned at the beginning that sleep is a critical issue. You know, if you look at the statistics of this country, our sleep is definitely an issue between work and stressors and pain. There’s so many things that impact our sleep, and it’s an easy thing to start attacking. So, the very first thing I always whenever I meet a patient is I ask them, how is your sleep? Do you have any issues with sleep? The question is, do you have trouble falling asleep? Do you have trouble staying asleep? When you wake up, do you feel like you had a good night’s rest? If the answer is, “Yes, I feel well rested. No, I don’t have any trouble falling. No, I don’t have trouble staying asleep,” I don’t have to worry about sleep in that person. They’re completely covered. But I’ve had patients come to me and I can’t get them better. And then, you know, we’ve tried all these other things and I finally go, okay. Clearly, I’m missing something. Tell me more about your sleep. And then, I have them do things like show me their watch and their timing. And I have these young women that are you know, they’re mothers, and they’re working full-time, and they’re going to graduate school and they don’t go to sleep until 2am. And then, they’re up at 6am. You only gave yourself four hours of sleep, right? 

So, what we know about autoimmune and autoinflammatory diseases is that they’re genuinely worse if the body is stressed. So, you want to do whatever you can to minimize stress. So, one of the biggest questions I get all the time is, somebody comes to me because they have a positive rheumatoid factor, and maybe even a positive CCP, which is that really sensitive marker for rheumatoid arthritis. And they say, “Okay, but I don’t have any disease, what do I need to do to prevent it from coming on,” right? And I go through a whole litany of, okay, well make sure that you’re sleeping really well, make sure that you, you have all the sleep hygiene skills that you need and knowing you’re employing all of them. And I’ll talk about that in a minute. 

Make sure that you’re eating a healthy, well-balanced, anti-inflammatory diet. You’re minimizing processed foods, you’re minimizing red meat, you’re minimizing dairy. We know all of those things trigger inflammation, right? So, nutrition is huge. And nutrition is not something you hear often because we, especially physicians and so I think PA’s as well, because again, their model, their educational training is modelled very much more on the medicine model, which is they don’t treat nutrition at all, or have not. I should say that’s changing. Yeah, but one of my, I have a scribe right now. And she’s trying, she’s applying to medical school, and the school that she likes the best has the mandatory plant-based nutrition class. And I was just like beside myself excited to hear that. So, that’s super crazy exciting. So, nutrition absolutely matters; what we put into our mouth makes a difference. 

And then, managing stress, right. So, if you’re that person who’s trying to raise kids, work full-time and go to graduate school, and you don’t have a good support system to make that all happen, then you’re gonna have problems. And when you when I look back to the patients that I’ve had, often I meet them when they’re going through the middle of a stressor. And that’s what turned their disease on. So, I mean, I have this young woman who came to me with the first time ever, she had a black eye, and she was in the middle of, you know, not a healthy relationship. And she was trying to get out of it. And that was the presentation of her lupus. Over the next two years, she was good enough to say, “I’m getting out of this situation, it’s clearly not right.” But every time he took her to court, her platelet count would drop. So, we actually preemptively dosed her with steroids before she had to go to court so that that wouldn’t happen, and she wouldn’t end up in the hospital anymore. But so, my point is that often these diseases are turned on and then worsened by stress. 

Cheryl:  38:30

Yeah, that Harvard University Press has this really good, it’s like a 70-page digital download book called, like, ‘Understanding Chronic Inflammation’. I’ll find it, I’ll put it in the show notes. But I printed it out. Because I was like, this is such a helpful resource. I think that it goes into the science of how does stress, you know, trigger this and it doesn’t mean that your, like, a lot of times people feel like, “Oh, well, I’m they’re just telling me that like, it’s all my fault.” No, it’s this is a human thing, you know? 

Christine:  39:01

No, not at all. Yeah.  

Cheryl:  39:03

Yeah. And that, yeah, the good news is we can do something about it, you know.

Christine:  39:09

And on that same line, so that’s the emotional stress that you’re experiencing in your life, right, but there is a stress on your body. So, not taking care of your body, not exercising, not maintaining a healthy weight, also puts tremendous stress. Specifically weight we know to be its own problem. So, obesity and the fat cells, the adipose cells that we have in our body, they produce inflammatory cytokines. And those cytokines are what drive the inflammation. Cytokine is just a magical word for a chemical that triggers inflammation in the body. And then, smoking. We know that smoking has got a huge association with rheumatoid arthritis. It’s what drives the formation of that cyclic citrullinated protein, which is that CCP, that antibody that drives the disease. So, the more you smoke, the more you make that antibody, the higher — and I always tell my patients that think of the as antibodies and the drugs that we use are attempts to reduce the antibodies. And it’s like changing your army, right? If my army is big and strong, then the attack is much worse. But if I can lower those antibodies, make your army smaller, and then the attack is less intense. 

Cheryl:  40:16

Yeah, that makes a lot of sense. And I do think, you know, it’s very overwhelming as a patient, like, I’m trying to imagine people being like, “Well, I have to exercise and do my nutrition and stress and sleep,” you know, like, and it’s that I’m now, I am actually more stressed thinking about all the things I have to do. But, you know, I often say in, you know, in my Rheum to THRIVE, you know, program is all teaching people in bite-sized chunks about these different things. And I think it is really always helpful, helpful little guide, guidance, word of wisdom, I guess, I would say, start with one, you know, be like, this week —

Christine:  40:51

I was gonna say the same thing. I was gonna say, yeah, just just one step. That’s all you ever need to do. One step, one day. You know, again, it’s a marathon. It’s not a sprint. So, can I give you the one other definite analogy that I love for dealing with chronic pain? I think you’ve heard it before. And that is from Penney Cowan, who is one of the founders of the American Chronic Pain Association. And she, I don’t — I’m not sure if I’ve bastardized her description of it, but it works for me. And I think it makes sense when I describe it to patients. But she describes living with chronic pain, like driving your car, and having tires flat. And you have to fill your different tires with different things. And if you only focus on one tire, you’re not going to move smoothly through life. You need all four tires to be smooth to move forward. 

So, one tire is physical — and no, sorry, one tire is Western medicine, surgery, medications, injections, things that we can do to you. And all too often in this world, people focus on that tire and they don’t think about all the other things. So, that’s what we can do for you. And that’s the people who only focus there, they are the ones that keep coming back to me saying, “But I’m not getting better, I’m not getting better.” That’s because you still have three flat tires. So, now you gotta go to the other tire. 

The second tire is your physical strength and endurance. So, that’s the food you put into your body. That’s the sleep that you allow yourself to get. That’s the strength that you have around your muscles to support your joints. That’s all of those the weight that you maintain, that’s a whole second tire. But let’s say you take all the right medicine and you exercise and eat right and sleep right. You still have two other tires that could be flat, right? 

So, the third tire is your physical worth, your value, the social connections that you make in this world, the fact that you need to maintain them. And all too often people who live with chronic conditions, especially when it’s painful, they slowly, slowly extract people from their lives, they start to have a smaller and smaller pool because they feel like they can’t be reliable. And it’s just a frustrating situation. 

Cheryl:  43:07

Yeah. And sometimes they’re forced to because they’re — or not forced to but the people in their life say, “You’re too much for me,” like and I had some, I’m just just saying for, for the record that it’s really, like, upsetting sometimes that, you know, I’ve had people in my support groups who, you know, their husband left them because they’re like, “You’re just too much for me.” And it’s just like, wow, okay. Like, quality over quantity, I always say, with social connections, but sorry. So, that’s your third is.

Christine:  43:35

So, you are so right. Quality over quantity. A hundred percent. Yeah, you need a few good connections in this world. And you don’t need more, really, that’s all that matters in this world. Who are the people, who are the five people that are going to be there for you, when you’re really down? Those are the people that matter. I think that’s the number they say, if we all had five people that we can call. Yeah, it’s between 5 and 10. But anyways. And then, the fourth tire is — and Afton Hassett would love this one, right? It’s all the self-management things that you can do for your own. So, it’s the ability to pace and learning what the value of pacing is. It’s the ability to change your thoughts when they don’t work for you, when the thoughts are working against you. “Oh, I’m a loser. I can’t meet up with everybody. I can’t keep up with the workload. People are gonna think I’m a terrible worker. I’m a terrible mother.” 

All of that, being able to recognize that you’re doing that and changing those thought patterns, that’s a whole ‘nother tire. Your ability to problem solve, knowing that you let’s say you’re going to Hawaii and you’ve just run this podcast and you have to hurry up and clean it and get it online and and you got to pack and you have to take care knowing that you have those 15 things, if you plan ahead and you organize your life you don’t have to end up with a terrible pain flare. But if you don’t have any of those tools in your pockets or your armamentarium then you don’t do those things and you end up flaring miserably. Like, from a pain perspective, but also often turning on your disease more.

Cheryl:  45:05

It almost sounds, it’s a little bit of like, yeah, like an executive, I would almost lump that in my head into like executive functioning and like emotional self-management, too, like.

Christine:  45:15

Yes. It’s all about, it’s about also learning how to manage your thoughts, manage your emotions, manage your energy, right. And so, knowing how to do things like meditate, knowing how to take yourself. Recognizing, “Oh, I’m getting really stressed here.” So, learning how to take deep breaths, so you don’t let that stress get out of control. Those are all what we call self-managing tools. And that’s a whole tire in and of itself. So, you need all four of those things all the time. And it’s just like the gas pump, you got to constantly go and fill it up, right? So, you got to fill up those social connections, you got to retrain the body on making sure that you didn’t over schedule and that you are taking good care of yourself and you’ve got to make sure, “Oh, let me relook at the holidays just came up. I wasn’t eating well, let me let me revamp that.” And you know, making sure that if you’re on medications, you’re taking them properly. And if you’re not tolerating them, don’t just stop them talk to your provider about, “Hey, I don’t like this side effect, can we come up with something else?” If you don’t have that kind of an open relationship with your provider, then you need a different provider.

Cheryl:  46:22

A hundred percent. And I love this analogy and the — I don’t know whether I tend to make things maybe overcomplicated — but I think sometimes I would imagine almost being like a dynamically-sized tires situation where sometimes you’re putting more into one or you’re noticing that one of them is giving you more back like in different like seasons of your life, or maybe each tire is actually composed of like four different mini tires like maybe with the sleep, endurance and strength, you might find in nutrition, you may find you get a bigger bang for your buck on one versus the other. Like I don’t find, like for me, for example, nutrition does not seem to have a very immediate effect for me and inflammation. I don’t, I know and I follow generally 80% of time an anti-inflammatory eating pattern, 20% of time chocolate. No, but it just, whereas when I started adding strength training to my exercise regimen of cardio, it was immediate benefit to my brain fog, my fatigue, overall robustness. So, do you find that similar with your patients that they might find like one of these variables moves the needle for them?

Christine:  47:32

Well, so you said you just froze and I don’t know why you’re frozen but you’re frozen. 

Cheryl:  47:35

Oh, no! I still see you.

Christine:  47:39

So, we talked before about sleep. And I would say that sleep is the number one issue. But I think we have to fix the fact that you’re frozen. 

Cheryl:  47:46

Okay, I’m not frozen to me. 

Christine:  47:49

You asked me if some of the different tires maybe have different components and have different aspects of the components, you know, really make a big difference. And I do believe they do. I think there are. That’s why, because I often have such a short period of time with patients, I do focus on things like sleep. Sleep is one of the — you get a night’s sleep, you’re dramatically different. I mean, there are numerous studies showing that a lack of sleep leads to chronic pain or leads to more pain. There’s a study, the very first study that was done, I think it’s one the very first study, was done in Canada. And I’m blanking on the name of the author and I have it in my lectures. Hold on, I can tell you in a second. Moldofsky. Moldofsky. M-O-L-D-O-F-S-K-Y. He did one of the very first studies in the early 1970s. And he took a healthy group of college students, and he woke them up at intermittent times. After one week, they started to hurt. After two weeks, they felt like they were hit by a truck. And most of the people, you gave them to sleep back, they did better. One guy went on to develop fibromyalgia and the word on the street that I’ve read in the literature on him is that this one person actually sued him for causing this chronic pain state. Now I don’t know if that’s true or not. But my point is, think about it. Think about what you feel like when you get a crappy night’s sleep. The next day you feel so much more poorly. So, for me, that’s so easy. And let’s, can we talk a little bit about sleep now, and just like what the sleep hygiene things are?

Cheryl:  49:20

Please! Yeah, yeah. I think I was gonna just add one of the studies that I cite in the Rheum to THRIVE course that I found morbidly fascinating, it’s this study in 2012 in the journal is just called ‘Sleep’, a medical journal called ‘Sleep’. Sleep exacerbates fatigue, depression, and pain and rheumatoid arthritis. And they subjected people with rheumatoid arthritis to a sleep deprivation condition with a randomized control — oh, my gosh, people were in so much worse pain. It’s not surprising but you do have to validate these things with research. But okay, so yeah, what else, what are, what can we do to sleep better?

Christine:  49:57

So, the first thing, how many If I could see all the people that might be listening to this, if you could raise your hands, how many of you would say that you look at a device within 15 minutes of going to bed? Probably most people. 

Cheryl:  50:14

92%. 

Christine:  50:16

I hope you’re not one of those. 

Cheryl:  50:18

I stopped that in, literally, and I’m sad to say, because I’ve literally taught this to people to do is, like, do as I say, not as I do. I finally stopped in 20, about November 2023, I stopped looking. I had to physically put my phone out of the room. That’s the only way I could do it. I charged my phones outside the bedroom.

Christine:  50:37

And that is key. That’s what everyone should be doing, right. So, the point is, you could still look at his device, but you have to put it in night mode. And it needs to be one continuous thing that you’re looking at. Not a movie per se, it really should be a quiet book, in a perfect world. But the point is, if you’re looking at email, or you’re looking at Tik Tok, or you’re looking at an Instagram, every new screen that you see opens your brain and wakes you back up again. And the brain goes, “Okay, it’s not time to go to sleep.” So, of course, you’re gonna have trouble going to sleep. And it is incredibly, incredibly easy to fix. That is a behavioral technique that is very easy to fix. So, that’s the very first thing that I say. And then, the other basic principles of sleep hygiene are that you go to bed every day at the same time, you wake up at the same time, you’re supposed to use your bed for just sleep and sex and nothing more. You shouldn’t be eating, you shouldn’t be playing games in your — well, I mean, you could play some games, but they have to be sex related games.

Cheryl:  51:33

I mean, some of us are assuming a little, I feel like is just me being in the weeds as an OT, but I’m like, you really have to customize this to the person because there’s not going to be, you know —

Christine:  51:44

But just some basic things like your room should be cool. If your room is too warm, it tend to wake you up, right. Your room should be dark. We know that you go into a deeper sleep state if you have a darker room. So, those are some basic principles, right. The other really important principle that people don’t usually employ is that you should spend at least 30 minutes outside every day. That’s, yeah.

Cheryl:  52:07

In Seattle. Yeah, ideally, you want to be exposed to some sun, right? 

Christine:  52:11

Sun, in a perfect world.

Cheryl:  52:12

For your circadian rhythm. 

Christine:  52:14

It’s just fresh air. And with that also is motion, right? You’re going to sleep better if you’re more physically active. So, it’s, I mean, I have a patient I just saw last week who spends more than 12 hours of his day in bed and then spends the rest of his day in bed. I mean, so basically, he’s in his bed almost all the time. And then, he tells me, he can’t tolerate even physical therapy. Well, that’s because you have so deconditioned yourself, but then also complains that he can’t sleep well. You can’t sleep because you’re not active. So, you know, being active is part of — yeah, it’s very vicious cycle. 

Cheryl:  52:48

For people listening, you can, if you are bed bound, you can absolutely do physical therapy from bed there. It’s about, you know, you’ve start with moving your muscles against gravity. And that’s, that is the challenge that your body can do right then, start there, you know, it’s not, not all hope is lost if you’re mostly in bed. Anyway, continue. 

Christine:  53:06

I would say if you’re mostly in bed, no, no, all hope is not lost. I would, I typically with people that are that deconditioned, I actually don’t start with physical therapy, I start with occupational therapy. 

Cheryl:  53:17

Well, that’s what I am. So, that’s perfect. I like hearing that.

Christine:  53:20

So, you know, I try to work with occupational therapists that can help people to be able to, you know, get up, be able to make their bed, be able to make their breakfast, be able to and in between, if you have to basically be sitting or lying down most of the time, then that’s fine. But we do a slow progressive increase. And so, some of the other tools that I use are things like step counters, because and I tell people when I first meet them, don’t change anything. Let me see what it is at baseline. If at baseline, your steps are 200 steps a day, okay, fine, we’re going to slowly increase those steps. And you will be able to if you do it in a slow, progressive, and graded way, as you know as occupational therapists. But oftentimes you need that objective measure. 

Cheryl:  54:05

And I think it’s so important to measure your progress against yourself. And this is where the social media can be such a positive and a negative thing, because I somethings shares things like, wow, look, here’s a video of me, I’m literally at a gym, because that’s where my body’s at right now. Today, I’m able to go to a gym and lift weights, but I’m always so sensitive to people to, you know, those responses I get when people are like, “Well, that’s not realistic. For me, I can’t do that,” you know? And it’s like, no, but for me, it’s I’m trying to do a little bit more than I did last week. I’m trying to get a little stronger than I was. So, if what you’re at is that it’s really hard for you to walk from your house to your mailbox and you get fatigued doing that, you’re gonna work up to being able to work, you know, go ahead, go to the mailbox today. Do some things to strengthen yourself. Then can you go five steps past the mailbox, 10 steps? And that’s what we celebrate and get people excited about your movement and don’t get distracted, you want to kind of stay in your lane and don’t compare yourself to people who are, you know, just in a different place than you, you know. Sorry.

Christine:  55:10

No, that’s fine. No, it’s not, that’s super important one. One of my other tools I use on that same note is I say, “Okay, what could you comfortably do without feeling like you have to sit down for an hour afterwards, or without feeling like you’re done for two days,” right? If you tell me I went for a two-mile walk, but then I couldn’t move for two days, well, then you did way too much. So, you need to figure out what you can do comfortably. And then, I tell people to start at 50% of that. So, if you can walk to that mailbox and not be bothered, then I want you to start walking to that mailbox every single day, halfway. Every day, put those, be intentional. Put the shoes on, and start by walking to that mailbox half the way every single day, whatever your measure is, and then slowly progressively increase it. So that you have to move. You will not get better if you don’t move. And, you know, so you ask what are some other things? That’s pretty up their sleeve.

Cheryl:  56:08

Movement. Yeah. And, you know, I know I want to be sensitive to amount of time we have. We have time left, but I am curious, you know, we’re talking about with rheumatic disease, people with like rheumatoid arthritis are similar. Now we’re talking about like, what are the non-pharmacological things that they can do for like fibromyalgia or central sensitization, which someone might have with, you know, they might concurrently have that kind of pain along with their rheumatoid arthritis, or they may have separately. The nociplastic pain where their tissues might be, some degree of tissues are not damaged. Let’s just say, in a, for sake of example, somebody who does not have RA who just has fibromyalgia, let’s say, for example, are some of these the same things that they’d be doing?

Christine:  56:56

Totally the same. I don’t change it at all. It’s really no different, right?

Cheryl:  56:59

That was kind of a leading question. I just want to make sure.

Christine:  57:03

Yeah, I would go through the same exact mantra. And as you mentioned, everything that I say is completely individualized. So, let’s go back to that car, right, let’s go back to the four tires. When I meet you, when you come to my practice, I have a 12-page intake and it looks at what is your living situation? What is your work situation? What is your history of pain? What is your history? What’s your family history? What treatments have you tried? What’s your sleep like? What’s your mood like? I ask all of those questions. And then, I focus a coordinated effort with the patient, we negotiate what is the best, what do we need to do to fill those tires? And it’s going to be different for every single person. So, I’m always asked, “Christine, you specialize in fibromyalgia. How do you treat that?” And my answer is, there is no one treatment. It’s an individualized process. And it’s different for different people at different times. You know, so when you just had your new baby, right, it’s completely a different set of needs that you had then, then you might have now as you’re trying to work and manage a child and manage a family, right, it’s totally different demands on you. So, what you need to do is different in those states.

Cheryl:  58:09

Yeah, you really addressing, like, the context of someone’s life has a huge impact on function. And I think that’s what people are missing when they’re looking for like, what’s the formula? What’s the formula for me to decrease my pain? It’s not, I think about that meme from The Notebook — it’s not that simple! It’s not that simple!

Christine:  58:31

It is not that simple. But so, imagine, like, if I took you, you’re going along, you’re doing fine, you’re managing everything because you’ve got all these different techniques in place, but your mother gets sick. And now you’ve got to add to that regimen, taking care of your mother. And this is reality. This is the kind of stuff that happens all the time. So, when you come to me, and you’re flaring, and I can’t get you — or I had this woman, she had been so well controlled for years on this one treatment, and all of a sudden, she came in, she was out of control. And we just thought, okay, well, maybe the drug stopped working for you. So, we made a switch to another drug. Didn’t go through all the details of what else might be happening, because she was always just a straightforward RA patient and, you know, responded well to treatment. And a second visit and a third visit, she was no better. I’m like, what the heck. So, finally, I said to her, “What’s going on in your life?” And her son had been arrested and was in court. And she was going through the middle of the trial with him, you know, so there was nothing I could do to get her RA under control without recognizing and helping her through that aspect of a super crazy difficult time, right?

Cheryl:  59:37

That is not —

Christine:  59:37

And we just, yeah, we don’t take the time, unfortunately, in a lot of our medicine because we have 15 minutes with somebody. So, it’s, again, really important that you form a good, strong, trusting relationship with your provider so that you can go in and say, “Hey, it’s been a really crappy three months, this is what just happened.” So, that then I, as a provider, can say, Okay, I know I need to sort of adjust and maybe look at things differently than I would have if you were still moving along fine.

Cheryl:  1:00:02

Yeah, or refer potentially to the providers. Like, occupational therapy, we get 50 minutes with the patient. Now, that’s assuming the insurance approves it. It’s really annoying. But point being like, it’s, you know, I feel like I’m gonna give you, like if I had the power and I know people in high places, I could give you give you an honorary occupational therapy doctorate because like what you’re talking about is the exact, that exact we call it like a occupational profile, which is our intakes are very similar. Not just the internal factors of, you know, what’s your pain, fatigue stuff like that, but the external, extrinsic barriers or extrinsic supports to your function, you know. I always say like, somebody with mild RA is not, doesn’t necessarily by nature of having mild RA in terms of maybe their inflammatory markers, doesn’t by nature of having mild RA have a mild impact on their quality of life, because if they have mild RA with zero social and environmental supports, that person’s going to function worse than somebody with more moderate to severe RA. 

And in my case, I’ll give myself as an example. I had every possible, every possible socioeconomic advantage before I got diagnosed, other than being male. I had every other advantage. I didn’t even get my diagnosis until my parents hired a concierge doctor. Like, I was not believed by — and she didn’t believe me initially, either, that I was sick. She thought I was I was too anxious and I had an eating disorder, which I did not have. I had severe rheumatoid cachexia going from captain of my college team — I get so angry about this 21 years later. I went from being 130 pounds, all muscle, practically, to 105 pounds, and no one believed me that I wasn’t trying to lose the weight. And I was so — and I will say, sorry, for the record, those who listen to the me are like, “Oh, my God, she’s going on her rampage again.” I only had one joint, I only had one joint that I would say was painful. And I’m used to, I’m an athlete. I’m used to pushing through it. Like, yeah, if I really think about I’m like, yeah, my elbows were little sore. This is not registered at all on my scale of importance of life. You know, I was just like, I have a sprained finger, the sprained finger for like a year. That was not — so, I’m not saying that they should have diagnosed me with RA. But I’m saying that they should have known, they should have believed me that something else more was wrong. I’m so sorry. I don’t remember how we even got on the tangent. 

Christine:  1:02:27

Oh, no. But so, let me tell you what I tell people with fibro. When someone comes to me, and I don’t know what they have. And maybe, right now, all I can diagnose them with is fibromyalgia. I tell them, listen, I’m not saying you don’t have something. We’re always going to look because this is a diagnosis of exclusion. I hear you. I know you’re uncomfortable. We need to get you to get some quality of life back. I don’t know what medications to use perhaps to treat an underlying condition because I haven’t figured out what that is yet. But you are, what you’re experiencing is real. And let’s figure out how we can help you.

Cheryl:  1:03:02

Yeah, oh, man. I’m literally like healing in my heart. Like, I do this in my head sometimes. I think about what how my experience could have been different if I had someone like you honestly, because it’s just it’s really unfortunate that so many patients get put through, put through the wringer. And I remembered my initial, my initial point was just to say that even though I had moderate to severe RA at my diagnosis, the fact that I had such incredible supports, not just socioeconomic but family, emotional support from my parents, you know, social support, great boyfriend, sister, best friend, you know, friends from my soccer team. And I had, you know, it was like a seamless process, getting me on — no insurance barriers, got me on to Enbrel, went back to college to finish my senior year. I’m at a level of functioning, that is a lot higher than somebody who just, quote unquote, ‘just’ got diagnosed with only mere mild rheumatoid arthritis with they’ve got — they’re a single parent, they’ve got multiple kids, they’ve got a, they are responsible for everything, their stress levels are high, they don’t have good insurance like that. So, you can’t just look at the internal variables like severity of the disease, you have to look at the context that the person is living in. That was —

Christine:  1:04:20

One hundred percent. One hundred percent, I agree with you.

Cheryl:  1:04:25

We agree. We should rule the world. Everyone should be like us. That’s all my podcasts go to eventually, no. But so, I also want to use the time that we have to give you the floor to talk a little bit more about your long COVID and fibromyalgia clinic. I’m just so fascinated by this. What are you looking at? What are you finding? Tell me everything. 

Christine:  1:04:45

Well, so I started it because with fibromyalgia, they don’t have a place to go. They don’t really live anywhere, right? So, they kind of fall under rheumatology, kind of fall on their neurology, kind of fall under PM&R, and nobody really generally is very interested in taking care of them. People that live with chronic pain are — it’s a time-consuming process to get to the bottom of it to figure out what in that four paradigm you need to tweak, it takes time. And I was not having that time seeing patients in a regular clinic where I have a half-an-hour for a new patient, 15-minutes for, you know, a return patient. So, I said, I need to create something different, and I want to be able to give something different. So, the idea was to see patients in this clinic. 

And really, I try to tell people that what I am is a coach. And I’m just kind of here to tell you what tools are out there. But I can’t do that. You have to then do it. So, you know, Coach Reid can tell his team to do all the right things, but unless they carry it out, they’re not going to win the Superbowl, right. I mean, Patrick Mahomes, he took it upon himself to run that touchdown almost all the way in and then throw the final, the final throw that was on him in that last moment. So, that’s what I try to tell people is what I’m able to offer. But what I offer is my holistic approach. And that that comprehensive intake. And they also have a time, before they come to see me, every patient gets 15 minutes of the pharmacist, and they go through all of their pharmacy, all their pharmacology, because the polypharmacy that we see is just so outrageous. But also, I can’t think about how to treat you if I don’t know what you’ve tried before. So, that’s really, really important. And then, in our first visit, we have a detailed, you know, what are all the different things that you’ve tried. 

So, that’s what I offer. I also offer an educational session on here’s the science of fibromyalgia and long COVID. And why long COVID? So, the majority of people that suffer from long COVID, I mean, there’s lots of manifestations. I think, on the books, there’s over 100 different symptoms. But for the most part, the most common symptoms that we hear are fatigue, dyscognition, so trouble thinking and executive function problems, mood disorders, blood pressure problems, so dysautonomia is a big symptom. And these are all symptoms that people who live with fibromyalgia also contend with. So, there’s a huge crossover. And at this point in time, we don’t have any formal treatment. So, it’s, again, employing all these same exact assessment skills and evaluation tools. 

And then, when, I mean, I keep up with what’s happening with long COVID and what treatments we know. For example, there has been some positive evidence that getting vaccines helps, that taking Paxlovid, if you get COVID, will help reduce long COVID. There’s some evidence of the microbiome being adjusted with COVID. And the belief is that because of that microbiome having been altered, you’re now producing less 5-HT, which is serotonin. So, that difficulty thinking and focusing and depression is all related to the fact that you’re not making enough 5-HT. So, one of the treatments is a probiotic. So, again, going back to nutrition, and how important the nutrition and the microbiome are to your total body wellness. So, that’s why they’re together because the tools that I use for both of those kinds of patients. 

And, again, these are patients that people with long COVID that have ended up in offices, and people have said, “I don’t have anything else to do for you. I don’t know what to do,” you know, and I think that this all sits well in rheumatology, especially long COVID and Fibro, because I think we’re slowly realizing that post-viral syndromes often turn on autoimmune diseases. And, you know, sometimes it’s not immediate, sometimes it’s delayed. So, I always look for that. And as I said before, all of my patients, I do a screening to make sure we’re not missing an autoimmune process. And then, I tell my patients that once a year, I’ll redo that screening, or once a year or with new symptoms, so that we’re always keeping in mind that we may not know what you have, but we’re still looking. 

Cheryl:  1:09:09

That’s so key. And I, in my case, I did have something called the Coxsackievirus before my diagnosis. It was just like a throat blister. It was a couple years before, but I’ve always wondered if that was like the kind of —

Christine:  1:09:22

Well, so we were pretty sure that there is a genetic predisposition for each of the different autoimmune diseases. And then, it’s that epigenetics that turn it on right, so whether it was the stress you had in graduate school plus the fact that you got Coxsackie plus whatever. 

Cheryl:  1:09:38

Family history, yeah, I have a great aunt with RA. No immediate family like no parent, you know, parents or siblings, but my great, my grandma’s sister had it. And so, as a juvenile, juvenile arthritis, and she lived a long beautiful life, actually. But which wasn’t as common back, you know, back then, too, because they didn’t have treatments. But, you know, I think I think there is a lot of concern in the RA, you know, rheumatoid arthritis community about yeah, am I, you know, what would I, if I get — if I start having worse fatigue after I’ve had COVID, does that mean that it’s long COVID? Does it mean that my — but it’s like that Whack-a-Mole. Is it my disease just progressing? Like, oh, my medications aren’t working? Or is it that, is it long COVID? It’s kind of at the end of the day, I come back to uncertainty, being able to the skill of being able to tolerate and cope with uncertainty kind of has to be employed, because at a certain point, you can use these diagnostic things we talked about earlier with, you know, the bloodwork and trying to figure out okay, this is maybe probably not the RA, this is this, this is that by a certain point, you’re going to kind of, I mean, do you agree that you kind of get to a guessing game, at a certain point?

Christine:  1:10:49

I mean, it’s always you want to have an educated guess, right? 

Cheryl:  1:10:52

Yeah. An educated guess, yes. Yeah.

Christine:  1:10:55

So, for the most part, we can usually get to the bottom of what’s going on. 

Cheryl:  1:10:58

Oh, well, that’s good. 

Christine:  1:11:00

Yeah, yeah, I think for the most part, I mean, but that’s what rheumatology is, right? Rheumatology is investigative medicine. That’s what we love about it. Anybody who’s in rheumatology, for the most part, loves the fact that it’s, you know, all about the fact that these are patients that have been to three or four other people, nobody could figure out what was going on. And the chief complaint for most of my patients walking through the door is fatigue and pain. Okay, now, that could be how many different things?

Cheryl:  1:11:24

Literally thousands. And I think that I wrote down as you were talking, I did kind of type out stuff that I want to follow up on. But then I was like debating do I even go into this, is it’s another complicating factor. But it’s ME/CFS, like myalgic encephalomyelitis/chronic fatigue syndrome. That’s such a — that one is so tricky, because you really have to, as far as I understand, and correct me if I’m wrong, but the post-exertional malaise really complicates the degree to which, the way that you approach exercise and activity levels,

Christine:  1:11:57

Right, but it doesn’t mean you can’t approach exercise and activity, you just have to approach it differently. 

Cheryl:  1:12:03

So, what do you do with those patients? 

Christine:  1:12:05

Yeah, I try to work with a physical therapist and/or an occupational therapist that has knowledge of it, because you do have to work for them differently. So, for someone who doesn’t have ME/CFS, they can push through fatigue. But if you have ME/CFS, you can make it worse, right? You can create symptoms that feel like you have the flu coming on. Doesn’t mean that you can’t condition, you just have to condition differently in a slower process and in a slower way. So, I think that’s the key is you have to give hope that there is an answer. So, I want to tell you a good story. And this happens, I think, more often than I’m aware of. So, I saw a patient I hadn’t seen her for three years. And I was like, “Oh, my gosh, where have you been? I haven’t seen you.” And her statement to me was, “Well, I did everything you told me and I felt much better. I just needed a little reboot.” 

Cheryl:  1:12:55

Oh, reboot. I love it. I love that. Yeah, I mean, that’s great. Because I think, I guess this is my own having — I went to therapy. And I still, you know, go for checkups, like every couple of months. But for a while I was going weekly to a psychologist and then eventually a psychiatrist who does actual therapy, which I didn’t know psychiatrist did, by the way, like hour-long therapy, you know. 

Christine:  1:13:23

That’s pretty awesome if you can find someone that does. 

Cheryl:  1:13:24

Oh, my gosh, he’s like, he’s so popular now that he doesn’t even keep a waitlist. Like I got so lucky to get in with him. But anyway, he’s actually an OCD and phobia specialist. So, I was having kind of potential — who knows, it’s everything’s interrelated, but not directly related to my knowledge to the RA — I was starting to get claustrophobia and cleithrophobia, which is fear of being trapped. The only way it relates to RA is that I when I have a lot of when I’ve had a lot of pain, I had a car accident and a bunch of other stuff that happened to me in the mid-2000s, I started getting feeling trapped in my body and like, like having a panic attack. Like, I can’t get out of my body. Like I feel — 

Christine:  1:14:03

Yeah. I don’t like this body. I’m in pain. I don’t want to be in pain. 

Cheryl:  1:14:05

I’m in pain. Yeah, I had a lot of pain from my car accident. And then, I had, and like, anyway, yeah, I started fixating on like, what if I get locked in syndrome, and like, I can’t move and I’m stuck in my body even more. And like, so obviously needed therapy. So, I went to therapy, and one of the things —

Christine:  1:14:19

And you had thoughts that were not working for you. 

Cheryl:  1:14:21

They were not helpful. Those were not thoughts, those thoughts were not facts. Yeah. But it wasn’t CBT — so, what’s interesting about the approach that they use them in that’s really evidence, you know, based for phobias, at least is it’s not about you can’t argue with your thoughts. ‘Cause people, they know that — I know I’m actually like, let’s say I’m afraid of spiders. That’s an easier example. Because it’s not the one I deal with. It’s like you could tell someone all day long, like, get them to say logically like, well, what’s the, what are the facts about spiders? Is this doesn’t work because your brain doesn’t care. Your brain doesn’t care about logic right now. So, the thing that works is exposure therapy and having to know just expose yourself to the stimulus, but expose yourself to the sensation physically in your body and of your own and being able to expose yourself to that sense of uncertainty. So, how does this all relate to arthritis? Well, or chronic illness, or ME/CFS, or long COVID is at a certain point, you can get the, you get your best, you’ll give your best educated guess, and you get to a treatment plan. 

But what I found helpful, too, has been spending time saying, I’m, you know, even if the doctor tells me or the nurse practitioner tells me 99.9% chance this is going to work, there is always a degree of uncertainty to life, and learning to tolerate that and say, okay, well, instead of fixating on, well, I don’t know for sure, and how do I get that 99% to 100%, say, okay, well, how can I still proceed and have like a joyful life, you know, meaningful, vibrant life, because I can’t get stuck all day fixating on this. It’s not the life I want to have. So, anyway, that’s what I think that’s what a lot of people get, at least, you know, I know that when I run my Rheum to THRIVE support groups, it’s a very much like we’ve balanced between, you know, problem-solving, and solution-oriented, you know, self-management. And we also say, let’s just take a moment to support each other through the difficulty of this and say, “Yeah, this sucks,” like, let’s not make a mistake about it, and try to be like, you know, put a rainbow on top of like, a pile of crap. Like, it’s hard. It is hard. And let’s support each other through that, you know, I think —

Christine:  1:16:35

Well, I think I would —

Cheryl:  1:16:37

Yeah. Go on, I’m sorry. 

Christine:  1:16:39

Isn’t that sort of the whole idea of the spoon theory. Christine Miserandino —

Cheryl:  1:16:44

I don’t know how to pronounce the last name. But yeah.

Christine:  1:16:46

Yeah, I don’t either. But, you know, and it is hard to deal with, and you only get so much energy to deal with it. And that’s why, again, you know, making sure that you organize your life to make sense. So, it sucks, because you know what, before you had this condition, maybe you didn’t need to plan ahead. Maybe you didn’t need to be as organized. But now to get through the day, if you’re not, it means you flare. And so, now you’re gonna have to do things differently. And I think that uncertainty is key. But also accepting that life is not the same as it was before. It doesn’t mean life can’t be beautiful, but it is the same. And that goes for whether you have RA, whether you have fibro, whether you have long COVID, whether you have ankylosing spondylitis, and gout put together, you know, whatever crazy combination of diseases you have. You have them now, and life is different, but life can still be beautiful. I think that’s probably a good note we should leave on.

Cheryl:  1:17:47

Perfect. Well, and I think, yeah, that Acceptance and Commitment Therapy is the technique I find, that’s what my therapists use, and that’s what has been the most helpful for me. And it is evidence-based, you know, for chronic pain and developing that values-oriented, what is, what do I value? What’s important in my life? How to commit to moving towards that versus making your whole life just about, you know, like, slaying the dragon of your chronic illness? Because —

Christine:  1:18:16

Because then that dragon is in charge, right? If that’s, yeah, and you want to leave the dance and not let the pain or the disease leave the dance, right. So, on, there’s two other things I just want to do before I leave. I want to just highlight Dr. Afton Hassett, Dr. Afton Hassett’s book, I recommend it to all of my patients. So, what she’s done in ‘Chronic Pain Reset’, CPR for your pain. Think of it that way. Chronic pain reset. So, what she’s done is she’s taken the science on things like Acceptance and Commitment Therapy, DBT, CBT, and positive psychology, and she’s brought it all together in this one book. Thank you for having it available for us.

Cheryl:  1:19:01

Yes. We didn’t plan this.

Christine:  1:19:04

It is mandatory reading for my patients. I really, I mean, if I could spoonfeed it to them. That’s how important I think that that book is. And then, lastly, I’m going to leave you with the words of the very first rheumatologist I ever worked with. And his name was Mark Bernstein. And he introduced me to what fibromyalgia is. Well, he introduced me to all of what everything in rheumatology is, but in that he would leave patients with this parting word. He’d say, “Find the things in life that make you feel good and do more of that. And the things in life that make you feel bad, do less of them.”

Cheryl:  1:19:40

It’s so simple, it just might work. I love it. I love it. Thank you so much. I feel like there’s so much more we could talk to him. I feel we covered a lot in one, in one day. So, I really appreciate your time. You’re like totally a rock star. And I’m going to link everything — unfortunately for us social, chronically online people, Dr. Stamatos is not super online. That’s okay though. Fortunately for you, you’re not, because believe me, it can be a little overwhelming.

Christine:  1:20:10

And I’m trying to do too many things, I apologize.

Cheryl:  1:20:12

No, don’t apologize. I’m working on boundaries and saying ‘No’ to things too. So, it, believe me, it’s easier to say no to social media if you haven’t started it already than it is once you’ve started it.

Christine:  1:20:23

So, what I would say is, if anyone ever wants to get in touch if they want to be seen in our clinic, just go through you. And they can, you can communicate with me.

Cheryl:  1:20:31

Oh, yeah. And I don’t know why I don’t know — Okay. What city are you in? I know you’re in New York.

Christine:  1:20:38

Yes. I’m on Long Island. And I actually do, I do a lot of my patients virtually, but you have to, I have to at least meet you once physically. And then, I can’t see people in another state. 

Cheryl:  1:20:50

They have to be New York State residents. Okay. 

Christine:  1:20:52

Yeah, because I don’t have a license in another state.

Cheryl:  1:20:55

I really hope. We’re, in OT, we’re working on an interstate licensure compact. I don’t know if they’re doing that for any of these, too, but — 

Christine:  1:21:02

I think there’s been you know, with the pandemic, there was definitely an effort to do some of that. I have a ton of patients that go to Florida and Pennsylvania. And so, it’s definitely been an issue. But we don’t have the solution to it as yet. 

Cheryl:  1:21:15

Oh, well. I, yeah, I know everyone in New York who’s listening to this is rejoicing at the moment, like, I want to see her, she’s so cool. So, thank you so much. And I hope everyone enjoy this. And please, if you — I’m always trying to remind everyone at the end of the episode, that there’s going to be a video, if you’re listening to this on audio, you know, like Apple podcasts or whatever. There’s also a video if you want to see us gesticulating, and a full transcript.

Christine:  1:21:41

Because there was a lot of that. 

Cheryl:  1:21:42

There was a lot. We were hitting the microphones and it was fine. But, and there’s also a transcript, I provide a transcript of every episode for accessibility. And also, I actually like being able to review and look at some of the things we said and like pull out quotes and stuff. And so, if that’s kind of your learning style, more of that is on the Arthritis Life website, which is arthritis.theenthusiasticlife.net. That’s the full — I usually just say myarthritislife.net because that redirects to my website, but thank you so much, and maybe we’ll do a part two one of these days, too, but I know you’re a busy lady. 

Christine:  1:22:14

Thank you. 

Cheryl:  1:22:15

Thank you. Bye.

Christine:  1:22:16

Bye.

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