Fibromyalgia and Chronic Pain: Expert Advice from Dr. Martina Ziegenbein

In this episode of the Thriving with Arthritis Podcast, Dr. Diana Girnita, a double board-certified physician in Internal Medicine and Rheumatology, interviews Dr. Martina Ziegenbein, a renowned rheumatologist specializing in fibromyalgia. 
With 17 years of experience as a Rheumatologist, Dr. Martina Ziegenbein brings her special interest in chronic pain management without pills or interventions to the conversation, focusing on whole health wellness and a mind-body approach.

Key Discussion Points:

• Complex Nature of Fibromyalgia: Understanding the multifaceted aspects of fibromyalgia and its impact on patients.
• Role of the Central Nervous System in Chronic Pain: Exploring how the central nervous system contributes to chronic pain in fibromyalgia.
• Dr. Ziegenbein's Unique Approach: Focusing on self-compassion, somatic tracking, and emotional awareness therapy.
• Patient Stories: Real-life examples highlighting the need for time and dedication in patient care.
• Emotional Expression and Boundary Setting: The importance of emotional expression and setting boundaries in managing fibromyalgia.

Join us as Dr. Ziegenbein shares her expert insights and patient stories, emphasizing the significance of a holistic and compassionate approach to treating fibromyalgia. This episode offers valuable perspectives for anyone living with or caring for someone with fibromyalgia.

Tune in to discover effective strategies for managing chronic pain and fostering emotional well-being.

About Dr. Martina Ziegenbein is a double board-certified physician in Internal Medicine and Rheumatology with 17 years of experience. Originally from Slovakia, she completed her medical studies there before moving to the US in 2001, where she completed her residency and fellowships. Dr. Ziegenbein has a special interest in chronic pain management without pills or interventions, focusing on whole health wellness and a mind-body approach. She is committed to achieving optimal health outcomes for her patients.

Website: www.wholehealthrheumatologyofcapecod.com
Linkedin: https://www.linkedin.com/in/martina-ziegenbein-055193b1/
Facebook: https://www.facebook.com/profile.php?id=61553286054191

Transcript

  Welcome back to a new episode of driving with arthritis podcast. I'm your host, Dr. Diana Girnita, and today we're going to address a new topic, but. This one affects a lot of people that are wandering from doctor to doctor in order to get proper help.

This is a disease that for many years it was misdiagnosed, misunderstood, and many times mistreated. We will talk about fibromyalgia,  

Who's better to talk about fibromyalgia that an amazing rheumatologist, a specialist that not only that she diagnosed and treats people with fibromyalgia, but she also has a unique approach in the field of rheumatology.

Dr. Martina Ziegenbein,  welcome.  Thank you so much, Dr. Diana  Girnita for having me. I feel very honored and privileged to be here.  Dr. Martina Ziegenbein is a double certified physician in internal medicine and rheumatology. She has under her belt 17 years of practice in the field of rheumatology. She's originally from Slovakia, very close to my country, Romania, where I came from, and she completed her medical studies there.

She came in the United States in 2001. She completed a residency and fellowship here. She does have a very special interest in managing chronic pain without pills and other interventions in the traditional medical field. She's very focused on wellness. And the mind body approach and she's very committed to provide the best services to her patients.

Dr. Martina, you are here and I'm again very honored to have you. We're going to talk about everything that you know and we are very grateful that you give us your knowledge and your time. And I would like to invite you to share a story of one of your patients.  Thank you so much for the beautiful introduction.

So I was actually prepared to share three stories and I just saw a patient that I would like to share also, even though I just saw her and we started approaching this topic because she already had a breakthrough during the visit and I would like to highlight how powerful it is to talk about what's really causing pain in fibromyalgia. 

So tell us a little bit about what is fibromyalgia and who owns this diagnosis because we know that in our field and especially when I was trained, the emphasis was not on fibromyalgia itself. It was on other conditions, other immune conditions that were actually causing pain.  correlated or were actually sharing this diagnosis for our patients.

So give us an introduction.  Yes. Thank you for that question. What a loaded question it is. So in terms of the definition of fibromyalgia, it literally means having pain above and below the body on both right and left hand side, not necessarily at the same time. It can be fluctuating, but it has to be over three, more than three months period.

That's definition of a chronic pain, basically. And we do some, we do. Sometimes or nowadays, I should say, we have transferred from referring to patients as having fibromyalgia to calling them as having central sensitization to pain because the origin of fibromyalgia and other chronic pain condition has been proven to be in the central nervous system. 

So the central nervous system, the brain is sensitized to pain, and that's why we call it now central sensitization to pain, but it's a big, it's a big word. It's like many words to say. So I refer to then the pain as chronic pain. Many will still know it as chronic pain. Fibromyalgia. So we still use that, but  I think medical society is slowly transferring to central sensitization or global sensitization or chronic pain impression expression. 

So tell us your story, the patient story. Yes. So I would like to start with the patient I just saw today. So she does carry a diagnosis of rheumatoid arthritis. Okay. For which she had been on appropriate treatments, but over the years, she has had the diagnosis for about 17 years over the years. She has developed additional pains, even though her rheumatoid arthritis is controlled or is believed to be controlled.

She has pain in multiple areas, including  additional symptoms, fatigue, difficulty, sleeping, waking up on refreshed. And also being irritable and just feeling hopeless about her life. And she was in particularly bad spot today when she saw me because she hasn't slept well. She had a little bump with her partner.

They had a little, they didn't really argue, but She was trying to explain to him how she feels and he didn't want to hear about it. So she felt discouraged by that. And just telling all of these, telling me all of these things, how she has changed over the last four years, since she moved to Cape, she was, even though she had all of these problems, she always felt  upbeat and funny and enjoying life and in the last four years, which Have followed one of her surgeries.

She had a knee surgery.  She developed fatigue and just difficulty dealing with life. Have GA has gained weight and has been just feeling overwhelmed with all of her symptoms, including pain. And there were additional symptoms that are not necessarily relevant, but she had multiple areas of pain. So she comes to me, so this is the background and she feels very  discouraged by the situation.

And so what I did, we, so I let her tell me all the story and I did reserve longer time. I do want to say that you cannot accomplish that in a 15 minute visit. So that's why having extra time for patients is really important.  So I, she told me the story, I examined her and it was extremely reassuring for me to see that her rheumatoid arthritis was controlled.

Her exam was overall very good, very normal, I should say from the joint perspective.  And we started talking about the pain and her other symptoms, the fatigue, the irritability, the insomnia, and I started explaining the nervous system, what role the nervous system plays and how agitation of the nervous system, the chronic stress can lead to initiation of depression.

of multiple of these symptoms and then the symptoms potentiate one another. And it's like a vicious circle.  So she was responsive to that, but she still, she felt she was already doing a lot of things to calm down her nervous system. She has been meditating. She has seen a therapist. She does enjoy in activities that bring her joy. 

So we continued. So what has been the breakthrough? I will make it shorter. What has been the breakthrough when I started talking about how. What we tell ourselves and that can be conscious or unconscious, how, what we tell ourselves has effect on everything else. Basically what the, what is our, what our thoughts are, what our beliefs are affect everything down the stream down from there.

And as we were engaging in discussion, so we basically started focusing on what does it mean? To love oneself to to say kind words in our thoughts to ourselves, because she has been upset about her body, about her weight. So we started there and the revelation she has had as we continued the conversation, as I was explaining to her how our past hurts can lead.

To the impression of our nervous system that there is something wrong and there is this unrest or a threat perceived threat, how it can lead to cascade of events, including elevation of the initiation of the stress response and her aha moment was when she realized that. She has always felt her entire life that there was something wrong with her that she was too sensitive.

And there were, she had been, there were past hurts when she felt hurt and when injustice was done to her as a child. But instead of getting apology from the humans who did that, the response she got from the, from  people of authority and her parents is that you are too sensitive. Just tough it out.

You have it much better than I ever had.  And when she heard that, no, that's not how things are  when we, when there is any type of  hurt or when the child doesn't feel safe. That's not normal. And the  in ideal world,  we correct that by  taking care of it by then when it's being done, whether the child is being bullied or when there is anything with the family dynamic going on,  but in the world that is not ideal.

We have to look at that as we are adults and go back and basically validate ourselves and heal and correct the situation ourselves. So that was to her, that was a huge revelation that validation of basically years. of worry and conviction that there is something wrong with her.  There is, she's unlovable or she doesn't deserve all the good things because there is something, she's too sensitive.

So she just has to tough it out.  So we'll see where it goes. She felt very relieved immediately  during the visit, which was very gratifying for me to see because these kinds of revelations then lead to further steps down the road that the person takes.  Mean including re evaluating all of their circumstances and looking at them through a new light or new lens, new perspective.

Correct.  Yes, I think that you explain so much. You brought so much through this story and a lot of people will relate to, to, to this kind of situation. But like you said, you highlighted a few very important things. First, the amount of time that you give to your patients. because in a traditional setting when you meet a new patient in 15 minutes you would never be able to get so deep.

Then second, how complex this disease it is, how many layers you have to peel To get to the bottom of the problem and third to be there to help the patient because the work is on the patient, but you are there to help the patient and you actually brought.  An answer to my next question, why are people developing fibromyalgia?

And you already answered that, but let me ask you, because a lot of the people that do have fibromyalgia, they also have chronic conditions, but actually the chronic condition, like you said, might be part of that vicious cycle that you get into and might not be the problem of fibromyalgia. And there are other things.

way in your past that will trigger certain changes in your body. So why do you think people develop fibromyalgia? Let's educate our patients.  So that's actually I may not have, as we don't have all the answers. We don't know why two people growing up in the same  conditions or similar conditions, one of them, one of them develops fibromyalgia, the other doesn't.

We don't have all the answers. What we do know is that central nervous system gets sensitized. And what.  What are contributing factors are number one, adverse childhood experiences. There is now a good amount of data, good research. Confirming that people with high ACE score so high score on questionnaire of adverse childhood experiences,  the higher the score, the higher likelihood of developing several other conditions, not just pain, but also other chronic conditions, including heart disease, diabetes, cancer, even that's one contributor. We don't know why not. All of people with high ACE score developed. We don't know that. Number two is there are certain personality features, including, but not limited to. Okay. High level of conscientiousness the worrying, somebody who worries a lot or catastrophizes. That's me.

I call it awfulizing when our brain and offers us and we go there with our minds to the worst case scenario in certain circumstances that leads to activation of nervous system. People pleasers. High achievers.  Those are personality traits that lead to what we refer to as fibromyalgia phenotype, like basically the setup that is higher likelihood to develop fibromyalgia.

And then there are other things we don't really have good name for. We call it the biopsychosocial concept when biological factors, prior illnesses, or genes. Psychological means the trauma we experienced in the past and social, the upbringing they all together contributes in all like in three bubbles to the likelihood of developing  fibromyalgia or chronic pain.

Not any of them more than other, but usually it's a combination.  But what is the common denominator? What seems to be the common denominator is activating the centers in the brain that  Turn up the volume on pain and  down regulating or turning down the areas of brain that decrease the pain. So there is a mismatch and the central nervous system, the stress response activation seems to be playing a central role. 

So the answer then to what helps the pain, so there is a medication around, which I don't wish to discuss today because there is literature research on it and the medications help. I want, so this is what I'm going to say about medications. I do think that it helps to use medications. I look at it as helping to carry the load when there is needs for medications to help sleep or to control depression, anxiety.

Absolutely. I support that. And. It may be long term or it may be short term, but ultimately it's number two part, which is learning  or allowing the nervous system to feel safe. Whatever leads to safety of the nervous system that leads to improvement in pain long term. And that's what I was going to focus on today. 

We will talk about treatments in just a second, but before we get there, you know that many of our patients with autoimmune diseases like lupus, rheumatoid arthritis, or other autoimmune diseases, we Want to acknowledge or we don't want to acknowledge, but they do develop fibromyalgia and you touch a few points But if you can expand a little bit, why do you think those people with these conditions autoimmune conditions?

Do also develop fibromyalgia and then we'll talk about treatments  I see so I think currently it's estimated about third of our patients with autoimmune diseases inflammatory rheumatic condition such as lupus, rheumatoid arthritis, psoriatic arthritis, also develop fibromyalgia. I don't think I have a good response other than what I alluded to before chronic pain.

So they may start it, they may have started having pain initially from rheumatoid arthritis or lupus and chronic pain sensitizes the central nervous system To activating these other areas that could that then trigger chronic pain. I don't have, I don't think we don't have a one pathway. What I can tell you is that Dr.

Tor Wager, the famous neuroscientist and his team have worked on mapping brains of people with fibromyalgia, and there is a different pattern of how our brain looks like on a functional brain MRI.  when we have fibromyalgia as opposed to when we don't.  And to me, that's really fascinating. So functional brain MRI is a type of MRI that picks up on activity of the brain. 

And so which  parts are firing more and people with fibromyalgia, their brain activity looks different from those who don't. So there are real changes in the brain, nervous activity that  can be detected by MRI. To me, that was a fascinating research and validated multiple patients with chronic pain. 

That is also fascinating to me because now in our days, we can look at those and we can understand that when the patient says that it's hurting, it really is. And there are parts of the brain, like you said, that will activate. And the reverse is true. When you do certain things that I believe you're going to talk about, other parts of the brain will activate to calm that down.

Now, you mentioned about the traditional treatments for fibromyalgia and that's the easy way. I tell the patients, I tell my patients, the pill is the easy way. The heavy lift is on you when you have to change things in your life. So if you can touch a little bit about what are the treatments today, the traditional treatment, just to mention them, but what do you do different?

That's what we want to hear from you. What you as a specialist in fibromyalgia bring to the table for the patients to get better on the long term.  So in a nutshell, what I do differently is that I actually start engaging myself in some of those things that are taught. Rheumatologists are taught to instruct the patient or inform them, educate them about fibromyalgia.

And then it's. It takes multidisciplinary approach and it's multiple things that help, including but not limited to medications, physical therapy, engaging in activities they like, and then trying other things such as Tai Chi or yoga. Basically things that  in some way, all control decrease the tension of the nervous system or trigger relaxation response.

I should say that's the proper way.  And.  What I do with my patients, so I engage it, I do that part, I educate the patient about fibromyalgia and what I do differently. I, in addition to just that part about education, then we go ahead and start doing things that are actually known to decrease the  tension of the nervous system slash to trigger the relaxation response, which include Somatic tracking fears, self compassion, and catching and regulating our thoughts, plus emotional awareness therapy, or and I would like to mention, I cannot, I don't always do all of them in, because it's hard to be able to do it within the constraints Of office visit, but I definitely start patients on it.

And aside from my now private practice, I have, I am developing and I have developed course for. people with chronic pain. So I I'm starting actually this weekend with a couple of patients.  Absolutely great. This is absolutely great because as you said, sometimes you have to initiate, but then the patient has to digest that idea, prepare mentally for the idea, and then start implementing.

So give us examples about how can people practice  Because you mentioned so many techniques and we know that they do not apply to everybody. But let's say we have a patient or you have a patient, where do you start? How do you teach them? And give us examples.  Thank you. I and I didn't mean to  blurt out all of the things at once.

So thank you for breaking it down. That's what I do with my patients too. So the first thing is you diagnose them, right? You listen to their story, you examine them and you confirm. Yes, your diagnosis seems to be chronic pain or fibromyalgia. And the first part is explaining. The biggest part is explaining the fibromyalgia on.

or chronic pain are real pain that I stressed that several times. The pain is real, but it's not coming from your body. It is coming from your brain. The nervous system is firing up the pain level and you're feeling pain in the body, but it's starting in the brain. So this is basically the basics of neuroplasticity that the brain has changes that we can see on MRI, and it's causing you pain, but it's not damage in the tissue.

And then when I give them the good news about neuroplasticity, the plastic part is that the brain doesn't have to stay like that. It can change. It wasn't always like that. It developed this way and it can change. And this is what's going to help. So the first part is explaining what  neuroplasticity is.

And the second part is how to trigger the relaxation response. And I usually started with the self love and self compassion. And that's what's triggered all the tears today. And the patient I mentioned earlier, because Learning the concept of self love. First of all, it's not really discussed in doctor's offices for reasons that we discussed also earlier.

There is simply no time. The way our health care system works right now in traditional offices, you have 15 or 20 minutes when you're lucky. You have 30.  You may not be able to explain all of these things. Plus, Some physicians don't get the training or believe that that self love is actually part of care of a physician.

And I think maybe we, you and I, you can share your experience within some people would say talking about self love does not belong to a physician. They may say it's part of the therapist. And I say, we are not doing service to our patients if we don't tell them that we as physicians also believe in it.

That if we're leaving it to a therapist, and I'm not saying that we need to take care of all we are not therapists, but we are physicians. We know that information and to Explained it to the patient that we believe this is part of getting better. It just takes and they can continue with the therapist on it.

But to me, it's such a good way how to introduce the healing part.  So basically, we started about that and the tears were the  and many patients. They struggle, including myself. Actually, this is all like it takes one to know one, right?  To truly understand what it takes to love ourselves, to, to love oneself.

It's such a game changer because we don't tend to think about ourselves from in those terms.  Many people struggle with the sense that  when I, so we talked in this particular patient today, she said, I don't have any problems.  Loving my children. I love them to death. But then when I say how do you. 

How can you look at it like that  from that perspective at yourself? And that's when the tears came. She never allowed herself the same amount of love  as she allows for her children. So we talk about that and. Part of that is self compassion. So I lead them through basically an exercise when we present a situation that is not too high, like not 10 out of 10 severity, just let's say six out of 10 when whatever situation they have in their problem.

And I say, pretend it's your friend that comes to you and tells you all about that situation. What would you say to your friend? So we go through that and then I say now turn it around  and say these things to yourself. And then the tears usually always come because we are not used to treating ourselves with kindness, with love, with patience.

Sometimes the words we say to ourselves are so mean, we wouldn't want to be, we wouldn't want to, we wouldn't want to be friends with the person who says these things to us, right? But we say it to ourselves. Um, sometimes that's always needed.  And sometimes that's all the patient needs. 

The second step, so that's self compassion. The second part is somatic tracking, which is or second step. Sometimes I start with that. It's not, I want to stress, it's not always the sequence, but somatic tracking is a meditation that is focused on inducing safety or talking to our brain while focusing on our pain without judgment.

And explaining to our brain that we are safe and that the pain is not dangerous.  So that's somatic tracking and it's part of pain reprocessing therapy that was developed by Alan Gordon. He's a psychologist at Pain Psychology Center in your neck of the woods. He's in Los Angeles. And I think he has learned his original  inspiration was from John I'm so sorry.

I'm blinking on the name. Not Resnick, John Sarno.  He's very famous. He's not alive anymore, but he started the whole idea that chronic pain is a result of  repressed emotions, but also  increase threat level perceived threat by our brain.  So that's somatic tracking. Then we talk about our thoughts.

And that was, that's connected to self love very much in this particular patient I had today. We talked about how she never believed that,  how she always believed that there is something wrong with her.  So that's a thought and it takes  effort and time, or it takes, I'm sorry, I take it back. It takes clarity to change that.

But once you believe in your thoughts,  that you are worthy of love and belonging and all the joy. And once you, once the person can believe that it changes everything. I could see it on her face today. She was completely relieved. That kind of revelation is bring, it brings joy to my heart because It changes somebody's life and trajectory. 

And so the last part or the last part of the equation of the, of this pain reprocessing therapy is emotional express, I'm sorry, emotional awareness and expression technique. And I want to stress that I don't do all of it. I just explain  the concepts to the patient. And I usually do encourage them to work with a therapist.

But I do go over the principle. So the principle of that is that our  emotions. If they're not processed  can lead to this tension of the nervous system and that can trigger the process, even though it may not be conscious anymore, the process of a central nervous system stress response, the flight or fight response.

And sometimes these emotions are buried from all the way back in childhood.  When we were children, we might have been hurt or absorbed  opinions and beliefs of other people. And we, because we were kids, we are affected by our peers, by our parents. We absorb those beliefs and the things that are said to us.

And then we carry them with us until adulthood, we don't question them  until we are either forced to or until it's brought to our attention that we may have beliefs that are old and that are not serving us. But it usually starts with something that happens. It's usually starts with an emotion, something that made us feel certain way. 

This is fascinating because I never heard the physician talking about so complex.  Concepts and walking the patient through all these concepts, it takes time, it takes dedication, and it takes knowledge, which many physicians do not have. The reality is that we in medical school and in our training, we are very focused on diagnosing people and treating with medications.

Those are the options to understand the patient, to correlate to the patient, to go deep into the complexity of the human being. We are not taught to do you have to have a special gift like you to do that, and you have to have a special interest to be there for your patients and walk them through. a life of experience and make them understand that some of their beliefs might not be current and make them understand that pain is processed by our brain and it's a signal, that's what I tell my patients, that when you have Pain, your body is signaling that there's something wrong.

But pain, like you said, is not always pain that comes from a reason, like a, I would say a boo, but it can come from trauma, trauma that you have experienced for years. You also mentioned something that I feel like many patients struggle to express, and also they struggle with that, the understanding of people around them.

They have this.  They start to have this disconnect with their partner, with their, kids, with their friends and try to isolate themselves because that's not, they don't feel like people are understanding them. What do you advise them to do?

It's good question and I don't always have good answers or I don't have one good answer. When.  When I talk to patients, I focus on they are my priority.  I guess I would say two things. I usually say two things to them. Number one is that you can only control your own thoughts and your own actions, and you can do the best to explain yourself and your situation, but you cannot make somebody think differently or act differently.

You can just do your best to explain. And number two is that. I just tell them that they have to allow  to let go. They cannot it's part of the first one, actually you cannot control another person, but then not letting them, not letting them bother it when the other person  expresses that I don't understand or doesn't show support. 

And it's easier said than done, but I focus, I bring it always back to the patient. And actually, that was the other example I was going to give you. It was a patient in her late sixties. who had pain in her arms and legs for years and have not had any consistent relief. So she was sent to me a rheumatology for evaluation of possible lupus or autoimmune condition.

And I did not find anything inflammatory. I reviewed her labs and imaging. I examined her and we started talking about her situation.  I started talking about, no, I'm sorry. I started talking about the fibromyalgia  slash chronic pain situation, how it is a expression of  overacting nervous system, the flight or fight response.

And then we started to apply it to our situation. But it was her who realized that she has been so focused on and worried about her grandson's wellbeing. Basically he was taken,  her son got divorced and now his ex wife took the child away. And she was, the patient was so worried, sick about  the grandchild.

And then when we, I peeled it apart, she realized her son is going to always take care of his child, her grandchild. And she cannot control this woman who decided to.  pick that child up and take it to, somewhere to another state. When she realized that she cannot control the other person, but that her grandson was going to be okay, no matter what, because her son was going to take care of him. 

She said her symptoms within weeks got 80 percent better. She came to see me a couple of months later, and that was the only change. So what she did was she accepted that nervous system can make symptom, can make pain. That was the first thing. So she accepted the concept of neuroplasticity. And number two, she realized that she was Hanging on, she was holding on and thinking she can change somebody else's behavior that by the degree of her worrying, she can change what this woman is not going to do is are not going to do it was again, so gratifying, right? Because she only changed 1 thing, but it was life changing for her. To answer your question, I'm using so many words is. You'll have to realize you can only control your thoughts. And feelings. And number two, you have to figure out how not to let it bother you. 

Correct. And patients do not express themselves too much. They didn't express their emotions. You did mention about that, about expressing the emotions that they have  and also telling people around them how they feel. They, many times they feel, they don't feel they say they don't feel.  So many times patients will say, I don't feel good, but I don't explain what good means.

Or what's happening with them. So do you encourage your patients to express their emotions, whereas their loved ones? Of course, and we do it under the umbrella of you are  doing the, all the things you feel you need to do to take care of yourself. Like this is your job to take care of yourself. And part of it is. 

Explaining what is going on or how certain things make you feel. So I suspect you're talking about boundaries, right? Like when people, so it's I have, this is something I'm learning still myself, but I can, it's easier to spot in another person. And we talk about it under above, under the umbrella of what do you need?

Okay. To feel taken care of. And then so you express that  calmly to your partner or family. And then you have to decide what is your responsibility to take on. And what is their responsibility or what?  So it's not their responsibility to carry burden of somebody else.  But it is their responsibility to identify and process their own feelings, right?

Their own thoughts and emotions. This complex is very, it's very hard to understand, especially when you don't feel well, you don't know how to express that you don't really feel well. But as you said, if you create some boundaries and if you Tell the other people how you really feel about  even the words that you receive that might open some channels of communication and the patient will be able to express what they need in order to get something from the other people. 

I know the concept of fibromyalgia is so complex and we try to break it down and we will work on it. continue to do I'm very happy that you took some time and you gave so much from your knowledge and I'm excited that you started your practice. Tell us a little bit about your practice because I know there will be patients out there that need a doctor like you. 

Thank you for the platform to talk about it. I was just going to say that I don't think like the concept of pain, in my opinion, in my humble opinion, is not. Complex because it really is that the pain comes from the brain. The things we need to do may feel hard because they don't come natural, right?

To love ourselves, to have self compassion for ourselves. to talk to our brain from the perspective of no judgment and learning a way how to induce safety that is hard. But in my opinion, the concept of pain is not that hard to, especially now with all the evidence we have, from neuroscience research.

Yes. In, yeah, and it takes time. You hit on that before it takes time. So my private practice I just opened in November 30th. It's in Mash p Cape Cod. I do I am com. I'm a hybrid, meaning I take insurance, but currently only Medicare, B part B, and the rest is cash paying customers. What I'm different the way I differ from other. 

private practices is that I do spend more time with patients and as we just discussed at the beginning and during it takes time to uncover these things to uncover what lies behind the pain, so to speak, because everybody has a story and you cannot get the story in 15 or 20 minutes. You need that just to examine and get familiar with their medical charts.

In order to get to the story and be able to help somebody, you need the time. So that's the difference. And my, the other big difference is that I do care. I do want to hear the pain stories because the sense of accomplishment and, , elation that comes from uncovering something for the patient that they were blind to is just. 

It's so sweet, this the sensation of a victory, so to speak. But you also have the knowledge because not all of us have that kind of knowledge and you have the training, extra training to, to assess the patient and also to guide them to the right people and guide them towards the right approach.

And you also created a course that is a valuable resource for patients with fibromyalgia. I don't know anybody else. A physician, because that's another thing. I don't know another physician who created a course for fibromyalgia. So that's why I believe that you have a unique approach and unique qualifications for patients to, to find you and to get the right help from you.

And where patients can find you, do you have a website, a phone number that you can leave for  Thank you for mentioning the course. I renamed it to Winning at Chronic Pain because it applies to multiple other chronic pain conditions. And I'm starting with two candidates, two, two participants this Saturday, actually in Mashpee.

So my website for my private practice is Whole Health Rheumatology of Cape Cod. The spelling of whole is W H O L E. And it's, I don't know whether you can see it though. Is it upside down? Is the word? No, it's, we can see it very clearly. Whole Health Rheumatology of Cape Cod. is the website. And for my podcast and chronic pain information is at winning at fibromyalgia.

com. But I'm also on social media. I'm on Tik TOK and Instagram and Facebook. And I can share those links with you after the podcast.  

We'll post the links for the people Dr. Martina Ziegenbein 
Thank you very much. I really appreciate the time that you gave us, the knowledge that you gave us, and I hope to see you in a future podcast.

And from the bottom of my heart, thank you for what you do for patients across the United States.  
You're welcome. It was a pleasure to be here.