September 5, 2023 • 36 mins
Do you ever wonder why pain feels the way it does? Or how to manage it effectively? We're pulling back the curtain on these questions with our esteemed guest, Dr. Jonathan Reisman, a board-certified physiatrist from the Kayal Orthopaedic Center. Together, we navigate the elusive world of pain management, shining a light on the different types of pain - nociceptive, neuropathic, somatic, and visceral - and unveiling the intricate network of nerve fibers transmitting these signals to our brains.
But it's not just about the physical. We also delve into the psychological aspect of pain, underlining the integral role the doctor-patient relationship plays in addressing secondary gain issues. Understanding pain isn't merely a medical exercise; it's a human one too. We delve into the power of patient education, setting expectations before surgery, and addressing possible roadblocks that could hinder recovery.
We wrap up by impressing upon you the critical importance of multimodal pain management. From early and aggressive treatment to prevent chronic pain, to the application of preemptive anesthesia and regional blocks, we leave no stone unturned. We also explore the role of radiofrequency ablation, medication, and the often underplayed value of exercise, physical therapy, acupuncture and chiropractic in improving mobility and reducing pain. Tune in as we demystify the fascinating world of interventional pain management with Dr. Reisman.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello and welcome to another edition of the Kale
Ortho podcast.
Today is September 5th, 2023,and our special guest today is
our very own Dr Jonathan Reisman.
Dr Jonathan Reisman is a boardcertified physiatrist in the
area of physical medicine andrehab and we're so happy to have
him with us today to talk to usabout current concepts in
(00:23):
interventional pain management.
Welcome to the podcast, drReisman.
It's so happy to have you withus today.
Speaker 2 (00:28):
Thank you, Dr Kale.
I'm really happy to be here.
I'm really fortunate andexcited about getting a chance
to educate our patients aboutwhat I do.
Speaker 1 (00:34):
Awesome.
So why don't you, first andforemost, tell us a little bit
about yourself?
Speaker 2 (00:37):
Okay, so my name is Jonathan Reisman.
I am a PM&R physiatry certifieddoctor.
I did a pain medicinefellowship at the University of
Minnesota.
I grew up in New Jersey priorto traveling to Minnesota for
some of my more advancedtraining.
I did an internal medicineinternship in Staten Island.
(00:59):
And I'm married.
I have a few little children.
My wife is a speech therapistand my children have got you
know, five-year-old,three-year-old and
eight-month-old so busy at homeand at work.
I'm so excited to be here at theKale Orthopedic Center.
I love taking care of patientsand helping to have patients
(01:22):
control their pain and get ridof their pain, hopefully.
So as a physiatrist I ameducated in the musculoskeletal
system, the nervous system, andreally focus on patients'
function and well-being and howthey function in their life and
with other people.
Pain is a big part of that.
Pain can really challenge aperson's everyday life and make
(01:48):
ordinary tasks very difficult,make things a little upsetting,
and so I'm really honored thatthe job that I do is to try to
help people get rid of that pain.
It's a very team-oriented, teamapproach.
At the Kale Orthopedic Centerwe have a whole array of
board-certified orthopedicsurgeons in multiple disciplines
(02:08):
physical therapy, chiropracticcare, acupuncture, and I like to
work with all of those in theseother healthcare roles together
to come up with a plan,sometimes with our patients as
well, to try to decrease theirpain.
Speaker 1 (02:24):
So let's talk about pain in general.
Let's first and foremost startby defining pain and sort of how
it develops.
Why do we even feel pain?
Speaker 2 (02:34):
So that is a really important topic.
Pain gets defined as a person'snegative thoughts, feelings or
physical feelings about actualor anticipated pain.
Sometimes that can be spiritualpain, physical pain, emotional
pain.
All of those aspects can makeour body hurt and it can happen
(02:59):
to any part of our body.
Pain is importantevolutionarily speaking.
It's an alert that something iswrong.
If I have an injury to my hand,if my hand is on fire, I feel
acute pain.
If we put that fire out, I getsome excellent surgeons to help
my hand heal and that pain goesaway.
That's wonderful.
But sometimes people still havepain afterwards, when there's
(03:19):
no organic injury and someone'sstill experiencing pain.
That's what we call chronicpain and the body is trying to
warn us that we need to dosomething to make that pain go
away.
But sometimes we're not exactlysure what it is that we need to
do, so whether it's acute painor chronic pain.
That's kind of the role that Ibring to the practice in trying
to help patients decrease it.
Speaker 1 (03:41):
Can you define, for our viewing and listening
audience, the different types ofnerve fibers that may be
allowing our brain to even sensepain?
Speaker 2 (03:49):
Yeah, absolutely so.
When we experience pain, it allstarts with musculoskeletal
pain peripherally.
So we have an injury to ourskin, to our muscle, to our bone
, and that signal gets encodedand transmitted over to our
spinal cord and then the signalis transmitted in a different
(04:13):
electrical signal up to ourbrain and we register.
I have pain in my body and Ineed to do something about it.
Speaker 1 (04:22):
Yeah, there's different types of receptors,
right.
There's different types ofreceptors in our hands and our
feet and different parts of ourskin that tends to allow our
bodies to interpret that signal,right.
Speaker 2 (04:34):
There's nociceptors, there's C fibers, whether we're
talking about our peripheralnervous system or our central
nervous system, when we have ournerve, there's different
components to the nerve and,depending on what type of pain
or injury we're dealing with,we're going to send that signal
a little faster.
It might feel sharp, it mightfeel dull, it might feel burning
, and I ask my patients todescribe their pain so that I
(04:57):
can get some insight into whatexactly is going on with them.
Speaker 1 (05:01):
Right, there's pressure sensors, right,
nociceptors, proprioceptors anddifferent things like that that
allow the feedback to ultimatelyget to the brain.
Some of the nerves are sensorynerves and some of the nerves
are motor nerves and some of thenerves are mixed nerves.
But this is the way thatsensation is transmitted
(05:22):
ultimately to the brain Right,absolutely.
And so, speaking aboutdifferent types of pain, there's
also nerve pain, there'ssomatic pain, there's visceral
pain.
Can you just speak to that alittle bit?
Speaker 2 (05:35):
Yes, dr Kaili, that was an excellent question.
So when we talk about pain, wekind of break it down into two
main categories there'snociceptive pain and there's
neuropathic pain.
So nociceptive pain is painthat we feel, that is normal to
be feeling.
It's when we have physical orsharp experiences, whether
that's from externalmechanoreceptors on our skin, or
(05:59):
visceral pain from our organsor intestines, or somatic pain
from our muscles or bones.
That will usually benociceptive pain.
Neuropathic pain is whenthere's an injury to the nervous
system itself and we might feelpain that is out of proportion
(06:20):
to the expected pain that onemight experience.
And so when we have nosusceptive pain, we have a
certain time course and weappreciate that we're going to
be experiencing that pain and wemight put some ice or heat and
we might see a surgeon, we mightdo some therapy that pain will
decrease and diminish.
(06:41):
Nerve pain or neuropathic painis a little different and it
doesn't go away in the way thatwe expect.
Sometimes it can linger,sometimes it can wax and wane
and it can be very challengingfor patients to really
understand what's wrong.
And that's a lot of the painthat I tend to focus on.
If somebody has an aching pain,you fall and get up, you're
(07:04):
playing a basketball and you getbruised in the shoulder.
That muscular pain is kind of adull aching throb but sometimes
the nerve itself gets somedamage to it and sometimes that
feels a little bit more electricor burning.
So neuropathy or nerve damage,specifically that or pain that
(07:26):
comes from our spine.
So if the spinal nerves getdamaged, that pain that might
shoot down our arms or legs,that will feel burning or sharp
or stabbing and the experienceof that pain and the way it
feels is very different.
I find that a lot of patientsthey sometimes get confused by
the pain because it doesn't goaway in the expected timeline.
(07:50):
If I get a cut on my skin Iexpect it to kind of scab over
and heal in a certain timeline.
But sometimes nerve pain, itmight wax and wane, it might
just linger and we're leftwondering why we're feeling that
way.
Speaker 1 (08:05):
Exactly my point, because neuropathic pain is some
of the most difficult painconditions for us to treat,
largely due to the fact thatit's unpredictable how quickly,
if at all, that nerve willrecover, because a lot of that
resolution of that pain will bedictated by the integrity of the
nerve If the nerve ispermanently injured or not, and
(08:27):
that will often dictate theresolution, because nerves heal
very slowly relative to otherbody parts, for instance a
broken bone or a muscle tear,that type of noceoceptive pain
that you described.
It's predictable and when wecan expect resolution of those
symptoms.
But that is often not the casewith neuropathic pain and we'll
(08:48):
get into the management ofneuropathic pain in a little bit
.
Speaker 2 (08:51):
Yes, absolutely.
And so the thing withneuropathic pain is that some of
our audience members orhealthcare providers listening
to the podcast might recall thatdifferent muscles or different
parts of the body, differentareas of skin or different
reflexes, we have expectedspinal levels that we associate
(09:13):
them with.
So, for instance, the triceps,we think about C, or cervical
seven, but it's also a littlesix, it's also a little eight.
Same thing with the biceps, youknow it's, we think about it as
a C five, but there can also besome C six component.
And the reason that that'simportant is because there's
this other type of pain calledcentral sensitization of pain,
(09:35):
and that's another pain that Itry to focus on with my patients
as well, because there aremultiple levels of innervation.
Sometimes, when we have aninjury to one portion of our
body, when that pain signal istransmitted through our spinal
cord, it might start to lingeror activate other spinal levels
that it was not initially foundin, and sometimes that can sort
(09:59):
of create an entirely new pain.
And even after we have injury,even after a disc pops back into
place or a nerve is moved outof the way that was being
compressed, the pain might stillbe there.
And that's because we have thisnew type of pain called central
sensitization of pain, and Ilike to try and focus on that as
(10:20):
well.
Speaker 1 (10:21):
That's a great point.
So, as far as pain is concerned, dr Reisman, what factors
contribute to the severity of apatient's pain?
Speaker 2 (10:31):
So, off the bat, there's the degree of injury,
there's the mechanism of injury.
So if someone has an amputationof a limb, if it was due to a
vascular process such asdiabetes, or if it was due to a
traumatic injury in an accident,automatically that's going to
(10:54):
be a different type of pain.
There's the level of traumaassociated and the emotional
experience with the pain as well.
Sometimes you meet someone andthey've undergone a really
intense injury and their pain isnot so severe and you're a
little surprised.
They're taking it pretty well.
(11:14):
And then you can meet somebodyand you know they've stubbed
their toe, so to speak, and thepain is so severe and it is
absolutely ruining their day.
So sometimes the way we thinkabout pain and the way we
process pain can really make abig difference into how much it
bothers us, how much we feel it.
We can be distracted.
If I had a major surgery butthen I won the lottery five
(11:38):
minutes later, for a few minutesI might not be thinking about
the pain.
I'll be thinking about, youknow, how much the lottery
winnings were.
So our emotions, our thoughts,our feelings, our relationships
with other people, they can helpus to process that pain and I
think that that's important inincluding in patient care is
understanding when we're talkingto a patient, what sort of pain
(11:59):
are they dealing with and whatchallenges is it posing for them
, and when we think about all ofthose aspects, we can control
our patients pain better.
Speaker 1 (12:10):
What role do, for instance, mental health and
social status and social issuesplay in one's you know
interpretation of their painlevel?
Speaker 2 (12:21):
So this is a very interesting topic that I'm very
passionate about when someone ispart of a community or a family
that has gone through a lot ofdifficult times certain
communities have been through alot of trauma over time.
There are actually epigeneticchanges that occur that
influence the way their pain isprocessed, and there are lab
(12:44):
studies that show thatgrandchildren of people who have
been through some trauma can beinterpreting pain and stress
and that's what we're trying todo and feeling it in a different
way and they don't know.
They don't know that that's partof it.
They don't know why.
So somebody can have their kneereplaced and it might just hurt
a lot, and it might hurtdifferently than someone else's
and the surgery was doneperfectly, but they just feel
(13:05):
this pain and perhaps theirparents had a lot of pain or
their grandparents had a lot ofpain, and so when we talk to
them about that and when I talkto my patients about my pain, I
want to understand do you haveany relationships that are
challenging right now because ofthe pain that you're going
through?
And sometimes we'll refer themto a mental health provider if
(13:26):
there can be some extra helpthat they can get in processing
some of those things and I'llfactor that into the
interventional procedures thatwe'll do and discuss and the
timing.
Speaker 1 (13:38):
Do you believe in a psychosomatic component of one's
patient's pain?
Speaker 2 (13:44):
I definitely do.
I think that it's a littledifferent for everybody.
I like to start off with theassumption that pain is purely
organic and do a full diagnosticevaluation of the pain, but
then, once we've establishedwhat we think the pain
generators are which is a termwe use a lot what I mean by that
(14:06):
is, if I told you, I have somepain here in my arm, so there's
a number of things that can bethe reason for it.
It can be my skin, it can bethe muscle, it can be the bone.
And once we've figured out fromimaging, from
electrodiagnostics, what thereason for that pain is, we can
then begin to wonder how much ofit is also being influenced by
(14:27):
the person's psychological state.
Speaker 1 (14:29):
Yeah, we say that when patients are told it's all
in your head that is our way ofsaying it's a psychosomatic
condition, meaning that it's adiagnosis of exclusion.
We as physicians make sure thatwe rule out any real etiology
of that patient's pain and whennothing is found, we often
(14:51):
diagnose it as a psychosomaticcondition, which is rare but it
can happen, because certainlymental health issues and other
secondary gain issues cancontribute to one's level of
pain or interpretation of pain.
So, speaking of secondary gain,what are some of the issues
that come to play when patientsare seeing you for pain, when
(15:14):
you've deduced that it issecondary to secondary gain?
Speaker 2 (15:18):
So important in the doctor-patient relationship is
the doctor-patient relationshipand when you have established
care with a patient when Iestablished care with a patient
I have a duty to care for them,to diagnose medical illness, if
there is, and work with them tofigure out how to treat it.
Sometimes, as you kind ofalluded to, even in the presence
(15:41):
of an injury, there can stillbe secondary gain with it, and
so, whether it's purelysecondary gain, without organic
pathology, or a mix of the two,we have to have honesty in our
relationship between myself andmy patients and we try to focus
on what elements of their injurywe can heal and we expect to be
(16:03):
hurting them in the case ofpain, and we are just very
honest about the anticipatedrecovery that somebody might be
experiencing from their pain.
Certainly, yeah.
Speaker 1 (16:15):
So we are really just expounding on these issues only
because we'd like to emphasizethat there are a myriad of
factors that contribute topatients' pain.
It's not only organic in nature.
Sometimes there are secondarygains, sometimes there are
social issues, mental healthissues that can contribute, and
it's important to discuss thatthese things have to be
(16:37):
addressed by a doctor like DrReisman.
When we're managing thepatient's condition, we can't
just treat the organic condition.
We have to address all theseissues as well in order to make
that patient better.
So it's important to emphasize.
Speaker 2 (16:53):
That brings up something that's really
important to me and how I thenbring that into interventional
procedures.
So when a patient isexperiencing pain and they might
have some psychosocialcomponents trauma in the family,
some depression or anxiety orconcerns about work and their
(17:15):
ability to produce an income wethen have a conversation, the
patient and I, and we talk aboutwhat our options are.
And so, when it comes to doingan interventional procedure and
trying to influence the body'sability to decrease its pain,
I'll talk to the patient andeducate them, and I think that
education is really a big piecehere.
When a patient understands whythey are hurting and understands
(17:39):
that their pain is appreciatedand real.
To me as a physician, whetherit's organic or psychosomatic,
it's real.
It's causing suffering and it'simportant to me that we try to
decrease it.
So we'll talk about what ourprocedures are, we'll talk about
how they work, we'll make surepatients feel comfortable, what
(18:02):
they can expect, and thosefactors end up helping them to
feel a bit more comfortable, andthere are studies that show
that education can actuallydecrease the pain.
Speaker 1 (18:11):
That's a great great point that you just made, and
it's so important to me as anorthopedic surgeon because
there's so much in theorthopedic literature that
supports the fact that patientsundergoing orthopedic procedures
with a lot of pain going intosurgery or mental health issues
or secondary gain issues goinginto surgery clearly have much
(18:33):
lower outcome scores than otherpatients that are not going into
these surgeries with thesepreexisting conditions.
So it's so important for me toknow that we have a physician
like you on staff that can helpour patients get the best
outcomes after surgery.
But these are all things thatneed to be recognized.
Speaker 2 (18:51):
Yeah, there's.
You know, I've read some paperson that topic exactly this,
that type of pain that I haddiscussed previously central
sensitization of pain.
There are some patients thatcan be predicted.
You know who will have a betteroutcome after their knee
surgery in terms of pain.
When we can identify thosepatients, that's really the next
level of care and we're doing agreat job of that here at the
(19:14):
Kailer orthopedic center.
We communicate, myself andother team members, and when we
realize that there's a patientwho's having a hard time with a
certain injury or experiencing agreat deal of pain, sometimes
we will alter and adjust thetiming of pain reducing
procedures so that they can haveless pain going into their
(19:36):
surgery.
Speaker 1 (19:37):
Absolutely.
It's just so important for usbecause we like to have these
conversations with our patientsbefore surgery so we can set
expectations.
And when I have a patient thatis suffering, unfortunately,
from severe depression oranxiety, or a patient that is
suffering from an injury thatwas secondary to a work related
injury that may have somesecondary gain and want to stay
(20:00):
out of work a little bit longer,I do have these conversations
with the patients and make itclear to them that patients with
these conditions have pooreroutcomes after surgery and take
longer to recover.
I can have the same exact x-rayafter a total knee replacement,
for instance.
Both look perfectly aligned andpositioned and sized.
(20:20):
One patient will complain ofpain and be stiff and have poor
range of motion and the otherpatient will, for instance, have
an excellent outcome and getback to work within a few weeks.
And a lot of that has to dowith the psychosomatic
conditions or the mental healthissues or social issues that the
patient is bringing to thetable, and those are things that
(20:42):
need to be discussed prior tosurgery so that there is a full
understanding of theexpectations with respect to
outcome.
So, dr Reisman, we talked aboutpain in general, the different
types of pain and some of thedifferent factors that can come
to the table with the patientthat may influence their level
(21:03):
of pain that they're feeling andalso their outcomes after
certain procedures.
How do you, as aninterventional pain management
specialist and a board certifiedphysiatrist, address these
patients on a case by case basis?
Speaker 2 (21:17):
So that's an excellent question.
It all starts off with thepatient's history and generally
when I meet a patient I'vespoken to their physician
beforehand or read their chartbeforehand and I've learned
about what's gone on, and thathelps guide the questions that I
want to ask the patient.
So when I listen to a patientand give the patient the
(21:38):
opportunity to tell their story,hear the details and the things
that matter to them in theirstory, that not only clues us
into the physical parts of theirbody that hurt.
The words that they're usingmight tell us the type of pain
that they have, the way theydescribe it.
But then I ask them how it'sbeen for them in terms of the
(22:02):
hardships, if there's anytrouble with work, trouble with
family, to gauge any emotionalaspect to pain.
Once we've discussed whatthey're feeling, we go to really
diagnosing what the paingenerators are.
Physical examination, advancedimaging, electro diagnostics all
(22:23):
of those things together tell afull story and help us to
understand exactly why thepatient is in pain.
There are some parts of the bodythat figuring out the exact
pain generator can be reallychallenging.
So, for instance, around thesacroiliac joint in our low back
on the left or right side.
Sometimes we have pain thereand that pain might travel a
(22:45):
little bit down our thigh.
So when a patient says that alot of people think about
radiculopathy, automatically weassume that there's a nerve
that's injured or compressed andcausing a lot of pain.
But when we really listen tothe patient and ask very
specific questions and helpguide them to think about how
they want to communicate theirpain to us, we might learn that
(23:08):
it's not really radiculopathy.
It might be facet mediated painin a referral pattern that's
mimicking what we might expectfrom radiculopathy.
This can happen from thesacroiliac joint, from the
lumbar facet joints.
Similarly, sometimes we haveheadaches but they're really
coming from our facet joints orpain in our trapezius.
It could be coming from theshoulder, it could be coming
(23:30):
from the neck, and so by takingthe time to go through this with
our patients, asking them veryspecifically what they're
feeling and then a guidedphysical examination, that's
kind of the starting points whenwe take a look at imaging.
I like to pay attention to timecourse.
So sometimes patients mightshow that they have some
degenerative changes in theirspine, pretty significant
(23:53):
degenerative changes.
But when I ask them how longthey've been experiencing their
pain for they say it's only beenfor three or four weeks and I
try to figure out okay.
Well, if their pain is comingfrom these degenerative joints,
why would it have started tohurt three or four weeks ago?
I would have expected it tohurt a few years ago, maybe.
So that helps to guide ourdecision making.
(24:14):
When we think about whatprocedure we want to do to try
to decrease the patient's pain,we think about how fast we can
get them feeling better and howsafely and efficiently we can
decrease their pain.
Speaker 1 (24:25):
So, dr Reisman, I know I've spoken to Dr Aiden
about this in the past with whenit comes to management of pain,
but what is your take on theconcept of preemptive anesthesia
and addressing painpreemptively, trying to nip it
in the bud, as opposed toplaying catch up and addressing
it after it's full blown andextremely difficult?
Speaker 2 (24:47):
to manage?
That's a really importantquestion.
I think it's important that weaggressively treat our patient's
pain, and that's because onepain is lousy and it makes us
feel bad.
But the other reason is becausewe want to decrease the pain.
We don't want the tissues, thenervous system to get used to
feeling the pain, Because oncesomebody is feeling pain for a
(25:08):
long time, it becomes morechallenging to decrease that
pain.
When somebody is going to havesurgery, if they are feeling
pain for a long time prior tothat surgery or during that
surgery, it makes the recoverymore painful and it actually
leads to other medicalconditions that might develop
into chronic pain, such ascomplex regional pain syndrome.
(25:28):
We have our autonomic system andour autonomic system divided
into sympathetic andparasympathetic systems.
It's at our core as organismsand a lot of times pain and
trauma can get rooted in theautonomic system.
And by treating pain early andaggressively we can decrease the
(25:48):
likelihood that we're going tohave pain for a long period of
time.
There are studies with neonatesthat neonates who don't have
controlled pain, they're notable to express the pain to us,
that they can have changes totheir nervous system as they
develop.
The same thing happens withadults.
We can have pain that changesand my initial injury can be at
(26:11):
my shoulder.
If I don't treat that shoulderaggressively and decrease that
shoulder pain quickly, I mightend up with pain at my hand or
at my wrist.
So I think it's very importantfor us to quickly figure out why
someone is in pain.
It's important to get seen byyour physician, see your
orthopedist, figure out what canbe done and then simultaneously
(26:32):
, I think it's important that ifyou're experiencing that pain,
you need to come in and get seenand we can figure out a joint
plan for how to decrease thatpain and prevent it from
becoming chronic.
Speaker 1 (26:44):
I couldn't agree with you more.
As I alluded to in the past,the concept of preemptive
anesthesia is critical in thesuccessful outcomes of patients'
orthopedic surgeries.
The orthopedic literatureclearly supports that.
Patients going into surgerywith more pain have more pain
coming out of surgery.
So it's incumbent upon us asorthopedic surgeons to do
(27:06):
everything we can to manage thatpatient's pain prior to any
orthopedic procedure.
And in addition to that, whenwe're undergoing major
orthopedic procedures such aship replacement, knee
replacement, shoulder surgeryetc.
We often employ the usage of apreemptive block, a regional
block, by the anesthesiologistwho will block the nerve prior
(27:30):
to surgery so that the patient'sbrain never interprets that
pain signal from the surgicalevent.
In other words, when I'm aboutto perform an incision for a
knee replacement, if that nervethat goes from the brain to the
knee is numbed or anesthetizedby the anesthesial just prior to
(27:50):
surgery, that patient's brainwill never feel the pain from
the surgical incision.
So very often we employ theusage of a regional block or
preemptive anesthesia to helpminimize the patient's pain
after surgery by blocking thenerve before surgery.
And that concept is extremelyimportant in the successful
(28:11):
outcomes of orthopedic surgicalprocedures.
It's not only a regional blockthat's often performed, but
rather it's a multimodalapproach to the preemptive
management of that patient'spain.
So we will often block themorphine receptors in the brain,
for instance with some narcoticmedication.
There will be some localanesthetic which will block the
(28:34):
nerve itself, andanti-inflammatories often can be
given up until surgery as wellto block the inflammation
associated with the surgicalprocedure.
All of this contributes tohaving less pain after surgery
and it's very, very important inthe area of orthopedics and
pain management.
Speaker 2 (28:52):
I couldn't agree more .
In my training we did a lot ofradiofrequency ablation and so
those nerves that you alluded to, prior to a knee surgery, those
nerves can be blocked.
Sometimes if a patient is goingto be having knee surgery or
knee replacement but they mightnot get around to it because
something in their life iscausing it to be delayed, we can
(29:14):
do a radio frequency ablationand provide some relief of their
pain for a number of monthsuntil they're able to have that
knee replaced.
We can do this, as you alludedto, not only with interventions
but with appropriate guidedmedication as well.
So by understanding themechanism of the pain and if the
pain is coming from a somaticnerve receptor or from a
(29:35):
neuropathic agent.
If it's nerve pain, we mightwant to use something like
gabapentin.
If it is coming from the bone,tylenol or Advil can be very
effective.
I find often that Tylenol itselfmight be one of the most
underutilized medications.
A lot of times when I ask apatient, when I'm meeting them,
I'll ask them what have you usedfor your pain?
(29:57):
And people don't really mentionTylenol or Advil.
They go straight to talkingabout gabapentin and tramadol,
and a lot of times that Tylenol.
When I ask them.
I said did you ever take it anddid it help you?
And they said, yeah, you know,tylenol helps quite a bit and
I'll ask how frequently do youtake it?
And they'll mention that they,you know, maybe once a week.
(30:18):
People don't want to take it andthat's because there's a lot of
misconceptions with medicationsabout how much is a safe amount
.
We don't want to overdomedications, we don't want to
use them unnecessarily, but partof my training focused on
understanding the medications,why we would use different ones,
and I'll speak to my patientsabout letting them know how much
(30:40):
they can safely take.
So sometimes it is safe to takemore medication than somebody
is taking.
We're not speaking about opiatemedications.
That's generally not part of mytreatment plan.
There's a time and a place, butthe evidence is showing that
that is not really effective forlong term reduction in pain.
But things like Tylenol, advil,other more specific types like
(31:05):
Celebrex, gabapentin, lyricathere's sometimes one might want
to use one or another and I'llguide my patients about which
one's likely right for them.
Speaker 1 (31:15):
Right.
And the other thing that weshould emphasize is and we're
very fortunate at the KailaOrthopedic Center to be
surrounded by so many expertsthe etiology of pain is clearly
multifactorial, but I think it'simportant to mention and
emphasize that the management ofpain is multi-modal as well.
So at the Kaila OrthopedicCenter we have orthopedic
(31:37):
surgeons, we haverheumatologists, we have
physiatrists, such as yourself,interventional pain management
specialists, but we also havechiropractors and acupuncturists
, massage therapists andphysical therapists.
All of these teammates andhealthcare providers collaborate
with one another to manage ourpatient's pain, because it is
(32:00):
multifactorial and we don't justthrow one dart at the patient's
pain.
We sort of attack it from manydifferent angles with all these
different services that weprovide, because it's so
important to recognize that paincomes from a myriad of
different issues.
And in addition to all of this,sometimes we'll have to refer
(32:21):
the patients back to a mentalhealth counselor as well, or a
psychiatrist possibly for themanagement of their mental
health illnesses and things likethat.
Do you agree with that, drReisman?
Speaker 2 (32:31):
I couldn't agree more .
There's an entire branch ofpsychology, pain psychology and
in physical therapy as well painphysical therapy.
Sometimes a patient when I askif they've done physical therapy
, they'll share.
They did, but it made it worseand that's because they didn't.
They were feeling some pain,but pain psychologists will talk
(32:53):
to the patient about good painand bad pain and what type of
pain is important to feel and ispart of growth and what type of
pain you want to be nervousabout, and our physical
therapists can do that as well.
So when I put in an order forphysical therapy, I'll educate
the patient and I'll documentand communicate to a therapist
or to a chiropractor which typeof therapy I think is best for
(33:15):
that patient and somebody twopeople can have the same back
injury, but they might have verydifferent physical therapy
prescriptions because somebodymight need more strengthening
and somebody might need moreflexibility and pain reduction,
and so it's important to keep inmind the whole picture there.
Sometimes it's important thatpatients' families are included
(33:39):
and then other mental healthexperts as well.
We want to make sure that thepatient's mind and is being
treated, and if they need pain,pain psychologist or
psychiatrist, we'll need tobring them in as well.
Speaker 1 (33:51):
Great, I couldn't agree more.
I think that's one of the mostbeautiful things about our
practice.
I think that, since we haveeverything in house, it's truly
a one-stop shop for all yourorthopedic needs, and I mean
that sincerely.
A lot of our patients will endup seeing five, maybe even
sometimes 10 differenthealthcare providers in our
practice.
It's only because we want tomake sure we attack their
(34:14):
problem from multiple differentangles, because each one of our
experts has a different serviceor a different level of
expertise to the treatment ofour patient's underlying
condition, because it does needto be managed from many
different angles, and we want tomake sure we're not missing
anything, to make sure that weadequately address every single
(34:35):
contributing factor of theirpain.
And so that's.
We're very fortunate to havethe colleagues that we do at our
practice all under one roof tomanage that.
Speaker 2 (34:45):
I absolutely agree.
We've spoken about theimportance of quickly and
aggressively treating pain, andpart of why we can do that so
well at the Kaila OrthopedicCenter is because we have such
efficient communication betweendifferent team members.
A patient can see a physicaltherapist or a chiropractor and,
either during their session ortwo minutes afterwards, come
over to my office and let meknow about an update with that
(35:07):
patient, ask me my thoughts, orsometimes it goes both ways.
I'll ask a colleague, arheumatologist, a chiropractor,
an orthopedic surgeon, I'll askthem what they think about
something that one of mypatients in the rooms are
experiencing and then, on thespot, we come up with a
collaborative approach toquickly and efficiently get that
patient what they need in termsof their healthcare.
Speaker 1 (35:29):
It's important to recognize that if something's
not working, we just have to trya different approach.
We just can't keep doing thesame thing over and, over and
over again, and so that's thebeauty of having so many
different alternatives.
So it's important to recognizethat.
And you know, shift gears ifyou have to, even midstream.
So, Dr Reissman, this has beenan awesome time with you today,
(35:52):
getting to appreciate thedifferent factors that
contribute to patients' pain.
We're so happy to have you.
You're definitely an invaluableasset in the practice, because
we do know how ubiquitous theproblem of pain is, and thank
God for doctors like you thatcan help get our patients out of
pain.
We really look forward tohaving you care for many of our
(36:12):
patients for many years to come.
So thanks so much.
It's been a pleasure speakingwith you today.
Thank you, okay.
Hello and welcome to another edition of the Kale
Ortho podcast.
Today is September 5th, 2023,and our special guest today is
our very own Dr Jonathan Reisman.
Dr Jonathan Reisman is a boardcertified physiatrist in the
area of physical medicine andrehab and we're so happy to have
him with us today to talk to usabout current concepts in
(00:23):
interventional pain management.
Welcome to the podcast, drReisman.
It's so happy to have you withus today.
Speaker 2 (00:28):
Thank you, Dr Kale.
I'm really happy to be here.
I'm really fortunate andexcited about getting a chance
to educate our patients aboutwhat I do.
Speaker 1 (00:34):
Awesome.
So why don't you, first andforemost, tell us a little bit
about yourself?
Speaker 2 (00:37):
Okay, so my name is Jonathan Reisman.
I am a PM&R physiatry certifieddoctor.
I did a pain medicinefellowship at the University of
Minnesota.
I grew up in New Jersey priorto traveling to Minnesota for
some of my more advancedtraining.
I did an internal medicineinternship in Staten Island.
(00:59):
And I'm married.
I have a few little children.
My wife is a speech therapistand my children have got you
know, five-year-old,three-year-old and
eight-month-old so busy at homeand at work.
I'm so excited to be here at theKale Orthopedic Center.
I love taking care of patientsand helping to have patients
(01:22):
control their pain and get ridof their pain, hopefully.
So as a physiatrist I ameducated in the musculoskeletal
system, the nervous system, andreally focus on patients'
function and well-being and howthey function in their life and
with other people.
Pain is a big part of that.
Pain can really challenge aperson's everyday life and make
(01:48):
ordinary tasks very difficult,make things a little upsetting,
and so I'm really honored thatthe job that I do is to try to
help people get rid of that pain.
It's a very team-oriented, teamapproach.
At the Kale Orthopedic Centerwe have a whole array of
board-certified orthopedicsurgeons in multiple disciplines
(02:08):
physical therapy, chiropracticcare, acupuncture, and I like to
work with all of those in theseother healthcare roles together
to come up with a plan,sometimes with our patients as
well, to try to decrease theirpain.
Speaker 1 (02:24):
So let's talk about pain in general.
Let's first and foremost startby defining pain and sort of how
it develops.
Why do we even feel pain?
Speaker 2 (02:34):
So that is a really important topic.
Pain gets defined as a person'snegative thoughts, feelings or
physical feelings about actualor anticipated pain.
Sometimes that can be spiritualpain, physical pain, emotional
pain.
All of those aspects can makeour body hurt and it can happen
(02:59):
to any part of our body.
Pain is importantevolutionarily speaking.
It's an alert that something iswrong.
If I have an injury to my hand,if my hand is on fire, I feel
acute pain.
If we put that fire out, I getsome excellent surgeons to help
my hand heal and that pain goesaway.
That's wonderful.
But sometimes people still havepain afterwards, when there's
(03:19):
no organic injury and someone'sstill experiencing pain.
That's what we call chronicpain and the body is trying to
warn us that we need to dosomething to make that pain go
away.
But sometimes we're not exactlysure what it is that we need to
do, so whether it's acute painor chronic pain.
That's kind of the role that Ibring to the practice in trying
to help patients decrease it.
Speaker 1 (03:41):
Can you define, for our viewing and listening
audience, the different types ofnerve fibers that may be
allowing our brain to even sensepain?
Speaker 2 (03:49):
Yeah, absolutely so.
When we experience pain, it allstarts with musculoskeletal
pain peripherally.
So we have an injury to ourskin, to our muscle, to our bone
, and that signal gets encodedand transmitted over to our
spinal cord and then the signalis transmitted in a different
(04:13):
electrical signal up to ourbrain and we register.
I have pain in my body and Ineed to do something about it.
Speaker 1 (04:22):
Yeah, there's different types of receptors,
right.
There's different types ofreceptors in our hands and our
feet and different parts of ourskin that tends to allow our
bodies to interpret that signal,right.
Speaker 2 (04:34):
There's nociceptors, there's C fibers, whether we're
talking about our peripheralnervous system or our central
nervous system, when we have ournerve, there's different
components to the nerve and,depending on what type of pain
or injury we're dealing with,we're going to send that signal
a little faster.
It might feel sharp, it mightfeel dull, it might feel burning
, and I ask my patients todescribe their pain so that I
(04:57):
can get some insight into whatexactly is going on with them.
Speaker 1 (05:01):
Right, there's pressure sensors, right,
nociceptors, proprioceptors anddifferent things like that that
allow the feedback to ultimatelyget to the brain.
Some of the nerves are sensorynerves and some of the nerves
are motor nerves and some of thenerves are mixed nerves.
But this is the way thatsensation is transmitted
(05:22):
ultimately to the brain Right,absolutely.
And so, speaking aboutdifferent types of pain, there's
also nerve pain, there'ssomatic pain, there's visceral
pain.
Can you just speak to that alittle bit?
Speaker 2 (05:35):
Yes, dr Kaili, that was an excellent question.
So when we talk about pain, wekind of break it down into two
main categories there'snociceptive pain and there's
neuropathic pain.
So nociceptive pain is painthat we feel, that is normal to
be feeling.
It's when we have physical orsharp experiences, whether
that's from externalmechanoreceptors on our skin, or
(05:59):
visceral pain from our organsor intestines, or somatic pain
from our muscles or bones.
That will usually benociceptive pain.
Neuropathic pain is whenthere's an injury to the nervous
system itself and we might feelpain that is out of proportion
(06:20):
to the expected pain that onemight experience.
And so when we have nosusceptive pain, we have a
certain time course and weappreciate that we're going to
be experiencing that pain and wemight put some ice or heat and
we might see a surgeon, we mightdo some therapy that pain will
decrease and diminish.
(06:41):
Nerve pain or neuropathic painis a little different and it
doesn't go away in the way thatwe expect.
Sometimes it can linger,sometimes it can wax and wane
and it can be very challengingfor patients to really
understand what's wrong.
And that's a lot of the painthat I tend to focus on.
If somebody has an aching pain,you fall and get up, you're
(07:04):
playing a basketball and you getbruised in the shoulder.
That muscular pain is kind of adull aching throb but sometimes
the nerve itself gets somedamage to it and sometimes that
feels a little bit more electricor burning.
So neuropathy or nerve damage,specifically that or pain that
(07:26):
comes from our spine.
So if the spinal nerves getdamaged, that pain that might
shoot down our arms or legs,that will feel burning or sharp
or stabbing and the experienceof that pain and the way it
feels is very different.
I find that a lot of patientsthey sometimes get confused by
the pain because it doesn't goaway in the expected timeline.
(07:50):
If I get a cut on my skin Iexpect it to kind of scab over
and heal in a certain timeline.
But sometimes nerve pain, itmight wax and wane, it might
just linger and we're leftwondering why we're feeling that
way.
Speaker 1 (08:05):
Exactly my point, because neuropathic pain is some
of the most difficult painconditions for us to treat,
largely due to the fact thatit's unpredictable how quickly,
if at all, that nerve willrecover, because a lot of that
resolution of that pain will bedictated by the integrity of the
nerve If the nerve ispermanently injured or not, and
(08:27):
that will often dictate theresolution, because nerves heal
very slowly relative to otherbody parts, for instance a
broken bone or a muscle tear,that type of noceoceptive pain
that you described.
It's predictable and when wecan expect resolution of those
symptoms.
But that is often not the casewith neuropathic pain and we'll
(08:48):
get into the management ofneuropathic pain in a little bit
.
Speaker 2 (08:51):
Yes, absolutely.
And so the thing withneuropathic pain is that some of
our audience members orhealthcare providers listening
to the podcast might recall thatdifferent muscles or different
parts of the body, differentareas of skin or different
reflexes, we have expectedspinal levels that we associate
(09:13):
them with.
So, for instance, the triceps,we think about C, or cervical
seven, but it's also a littlesix, it's also a little eight.
Same thing with the biceps, youknow it's, we think about it as
a C five, but there can also besome C six component.
And the reason that that'simportant is because there's
this other type of pain calledcentral sensitization of pain,
(09:35):
and that's another pain that Itry to focus on with my patients
as well, because there aremultiple levels of innervation.
Sometimes, when we have aninjury to one portion of our
body, when that pain signal istransmitted through our spinal
cord, it might start to lingeror activate other spinal levels
that it was not initially foundin, and sometimes that can sort
(09:59):
of create an entirely new pain.
And even after we have injury,even after a disc pops back into
place or a nerve is moved outof the way that was being
compressed, the pain might stillbe there.
And that's because we have thisnew type of pain called central
sensitization of pain, and Ilike to try and focus on that as
(10:20):
well.
Speaker 1 (10:21):
That's a great point.
So, as far as pain is concerned, dr Reisman, what factors
contribute to the severity of apatient's pain?
Speaker 2 (10:31):
So, off the bat, there's the degree of injury,
there's the mechanism of injury.
So if someone has an amputationof a limb, if it was due to a
vascular process such asdiabetes, or if it was due to a
traumatic injury in an accident,automatically that's going to
(10:54):
be a different type of pain.
There's the level of traumaassociated and the emotional
experience with the pain as well.
Sometimes you meet someone andthey've undergone a really
intense injury and their pain isnot so severe and you're a
little surprised.
They're taking it pretty well.
(11:14):
And then you can meet somebodyand you know they've stubbed
their toe, so to speak, and thepain is so severe and it is
absolutely ruining their day.
So sometimes the way we thinkabout pain and the way we
process pain can really make abig difference into how much it
bothers us, how much we feel it.
We can be distracted.
If I had a major surgery butthen I won the lottery five
(11:38):
minutes later, for a few minutesI might not be thinking about
the pain.
I'll be thinking about, youknow, how much the lottery
winnings were.
So our emotions, our thoughts,our feelings, our relationships
with other people, they can helpus to process that pain and I
think that that's important inincluding in patient care is
understanding when we're talkingto a patient, what sort of pain
(11:59):
are they dealing with and whatchallenges is it posing for them
, and when we think about all ofthose aspects, we can control
our patients pain better.
Speaker 1 (12:10):
What role do, for instance, mental health and
social status and social issuesplay in one's you know
interpretation of their painlevel?
Speaker 2 (12:21):
So this is a very interesting topic that I'm very
passionate about when someone ispart of a community or a family
that has gone through a lot ofdifficult times certain
communities have been through alot of trauma over time.
There are actually epigeneticchanges that occur that
influence the way their pain isprocessed, and there are lab
(12:44):
studies that show thatgrandchildren of people who have
been through some trauma can beinterpreting pain and stress
and that's what we're trying todo and feeling it in a different
way and they don't know.
They don't know that that's partof it.
They don't know why.
So somebody can have their kneereplaced and it might just hurt
a lot, and it might hurtdifferently than someone else's
and the surgery was doneperfectly, but they just feel
(13:05):
this pain and perhaps theirparents had a lot of pain or
their grandparents had a lot ofpain, and so when we talk to
them about that and when I talkto my patients about my pain, I
want to understand do you haveany relationships that are
challenging right now because ofthe pain that you're going
through?
And sometimes we'll refer themto a mental health provider if
(13:26):
there can be some extra helpthat they can get in processing
some of those things and I'llfactor that into the
interventional procedures thatwe'll do and discuss and the
timing.
Speaker 1 (13:38):
Do you believe in a psychosomatic component of one's
patient's pain?
Speaker 2 (13:44):
I definitely do.
I think that it's a littledifferent for everybody.
I like to start off with theassumption that pain is purely
organic and do a full diagnosticevaluation of the pain, but
then, once we've establishedwhat we think the pain
generators are which is a termwe use a lot what I mean by that
(14:06):
is, if I told you, I have somepain here in my arm, so there's
a number of things that can bethe reason for it.
It can be my skin, it can bethe muscle, it can be the bone.
And once we've figured out fromimaging, from
electrodiagnostics, what thereason for that pain is, we can
then begin to wonder how much ofit is also being influenced by
(14:27):
the person's psychological state.
Speaker 1 (14:29):
Yeah, we say that when patients are told it's all
in your head that is our way ofsaying it's a psychosomatic
condition, meaning that it's adiagnosis of exclusion.
We as physicians make sure thatwe rule out any real etiology
of that patient's pain and whennothing is found, we often
(14:51):
diagnose it as a psychosomaticcondition, which is rare but it
can happen, because certainlymental health issues and other
secondary gain issues cancontribute to one's level of
pain or interpretation of pain.
So, speaking of secondary gain,what are some of the issues
that come to play when patientsare seeing you for pain, when
(15:14):
you've deduced that it issecondary to secondary gain?
Speaker 2 (15:18):
So important in the doctor-patient relationship is
the doctor-patient relationshipand when you have established
care with a patient when Iestablished care with a patient
I have a duty to care for them,to diagnose medical illness, if
there is, and work with them tofigure out how to treat it.
Sometimes, as you kind ofalluded to, even in the presence
(15:41):
of an injury, there can stillbe secondary gain with it, and
so, whether it's purelysecondary gain, without organic
pathology, or a mix of the two,we have to have honesty in our
relationship between myself andmy patients and we try to focus
on what elements of their injurywe can heal and we expect to be
(16:03):
hurting them in the case ofpain, and we are just very
honest about the anticipatedrecovery that somebody might be
experiencing from their pain.
Certainly, yeah.
Speaker 1 (16:15):
So we are really just expounding on these issues only
because we'd like to emphasizethat there are a myriad of
factors that contribute topatients' pain.
It's not only organic in nature.
Sometimes there are secondarygains, sometimes there are
social issues, mental healthissues that can contribute, and
it's important to discuss thatthese things have to be
(16:37):
addressed by a doctor like DrReisman.
When we're managing thepatient's condition, we can't
just treat the organic condition.
We have to address all theseissues as well in order to make
that patient better.
So it's important to emphasize.
Speaker 2 (16:53):
That brings up something that's really
important to me and how I thenbring that into interventional
procedures.
So when a patient isexperiencing pain and they might
have some psychosocialcomponents trauma in the family,
some depression or anxiety orconcerns about work and their
(17:15):
ability to produce an income wethen have a conversation, the
patient and I, and we talk aboutwhat our options are.
And so, when it comes to doingan interventional procedure and
trying to influence the body'sability to decrease its pain,
I'll talk to the patient andeducate them, and I think that
education is really a big piecehere.
When a patient understands whythey are hurting and understands
(17:39):
that their pain is appreciatedand real.
To me as a physician, whetherit's organic or psychosomatic,
it's real.
It's causing suffering and it'simportant to me that we try to
decrease it.
So we'll talk about what ourprocedures are, we'll talk about
how they work, we'll make surepatients feel comfortable, what
(18:02):
they can expect, and thosefactors end up helping them to
feel a bit more comfortable, andthere are studies that show
that education can actuallydecrease the pain.
Speaker 1 (18:11):
That's a great great point that you just made, and
it's so important to me as anorthopedic surgeon because
there's so much in theorthopedic literature that
supports the fact that patientsundergoing orthopedic procedures
with a lot of pain going intosurgery or mental health issues
or secondary gain issues goinginto surgery clearly have much
(18:33):
lower outcome scores than otherpatients that are not going into
these surgeries with thesepreexisting conditions.
So it's so important for me toknow that we have a physician
like you on staff that can helpour patients get the best
outcomes after surgery.
But these are all things thatneed to be recognized.
Speaker 2 (18:51):
Yeah, there's.
You know, I've read some paperson that topic exactly this,
that type of pain that I haddiscussed previously central
sensitization of pain.
There are some patients thatcan be predicted.
You know who will have a betteroutcome after their knee
surgery in terms of pain.
When we can identify thosepatients, that's really the next
level of care and we're doing agreat job of that here at the
(19:14):
Kailer orthopedic center.
We communicate, myself andother team members, and when we
realize that there's a patientwho's having a hard time with a
certain injury or experiencing agreat deal of pain, sometimes
we will alter and adjust thetiming of pain reducing
procedures so that they can haveless pain going into their
(19:36):
surgery.
Speaker 1 (19:37):
Absolutely.
It's just so important for usbecause we like to have these
conversations with our patientsbefore surgery so we can set
expectations.
And when I have a patient thatis suffering, unfortunately,
from severe depression oranxiety, or a patient that is
suffering from an injury thatwas secondary to a work related
injury that may have somesecondary gain and want to stay
(20:00):
out of work a little bit longer,I do have these conversations
with the patients and make itclear to them that patients with
these conditions have pooreroutcomes after surgery and take
longer to recover.
I can have the same exact x-rayafter a total knee replacement,
for instance.
Both look perfectly aligned andpositioned and sized.
(20:20):
One patient will complain ofpain and be stiff and have poor
range of motion and the otherpatient will, for instance, have
an excellent outcome and getback to work within a few weeks.
And a lot of that has to dowith the psychosomatic
conditions or the mental healthissues or social issues that the
patient is bringing to thetable, and those are things that
(20:42):
need to be discussed prior tosurgery so that there is a full
understanding of theexpectations with respect to
outcome.
So, dr Reisman, we talked aboutpain in general, the different
types of pain and some of thedifferent factors that can come
to the table with the patientthat may influence their level
(21:03):
of pain that they're feeling andalso their outcomes after
certain procedures.
How do you, as aninterventional pain management
specialist and a board certifiedphysiatrist, address these
patients on a case by case basis?
Speaker 2 (21:17):
So that's an excellent question.
It all starts off with thepatient's history and generally
when I meet a patient I'vespoken to their physician
beforehand or read their chartbeforehand and I've learned
about what's gone on, and thathelps guide the questions that I
want to ask the patient.
So when I listen to a patientand give the patient the
(21:38):
opportunity to tell their story,hear the details and the things
that matter to them in theirstory, that not only clues us
into the physical parts of theirbody that hurt.
The words that they're usingmight tell us the type of pain
that they have, the way theydescribe it.
But then I ask them how it'sbeen for them in terms of the
(22:02):
hardships, if there's anytrouble with work, trouble with
family, to gauge any emotionalaspect to pain.
Once we've discussed whatthey're feeling, we go to really
diagnosing what the paingenerators are.
Physical examination, advancedimaging, electro diagnostics all
(22:23):
of those things together tell afull story and help us to
understand exactly why thepatient is in pain.
There are some parts of the bodythat figuring out the exact
pain generator can be reallychallenging.
So, for instance, around thesacroiliac joint in our low back
on the left or right side.
Sometimes we have pain thereand that pain might travel a
(22:45):
little bit down our thigh.
So when a patient says that alot of people think about
radiculopathy, automatically weassume that there's a nerve
that's injured or compressed andcausing a lot of pain.
But when we really listen tothe patient and ask very
specific questions and helpguide them to think about how
they want to communicate theirpain to us, we might learn that
(23:08):
it's not really radiculopathy.
It might be facet mediated painin a referral pattern that's
mimicking what we might expectfrom radiculopathy.
This can happen from thesacroiliac joint, from the
lumbar facet joints.
Similarly, sometimes we haveheadaches but they're really
coming from our facet joints orpain in our trapezius.
It could be coming from theshoulder, it could be coming
(23:30):
from the neck, and so by takingthe time to go through this with
our patients, asking them veryspecifically what they're
feeling and then a guidedphysical examination, that's
kind of the starting points whenwe take a look at imaging.
I like to pay attention to timecourse.
So sometimes patients mightshow that they have some
degenerative changes in theirspine, pretty significant
(23:53):
degenerative changes.
But when I ask them how longthey've been experiencing their
pain for they say it's only beenfor three or four weeks and I
try to figure out okay.
Well, if their pain is comingfrom these degenerative joints,
why would it have started tohurt three or four weeks ago?
I would have expected it tohurt a few years ago, maybe.
So that helps to guide ourdecision making.
(24:14):
When we think about whatprocedure we want to do to try
to decrease the patient's pain,we think about how fast we can
get them feeling better and howsafely and efficiently we can
decrease their pain.
Speaker 1 (24:25):
So, dr Reisman, I know I've spoken to Dr Aiden
about this in the past with whenit comes to management of pain,
but what is your take on theconcept of preemptive anesthesia
and addressing painpreemptively, trying to nip it
in the bud, as opposed toplaying catch up and addressing
it after it's full blown andextremely difficult?
Speaker 2 (24:47):
to manage?
That's a really importantquestion.
I think it's important that weaggressively treat our patient's
pain, and that's because onepain is lousy and it makes us
feel bad.
But the other reason is becausewe want to decrease the pain.
We don't want the tissues, thenervous system to get used to
feeling the pain, Because oncesomebody is feeling pain for a
(25:08):
long time, it becomes morechallenging to decrease that
pain.
When somebody is going to havesurgery, if they are feeling
pain for a long time prior tothat surgery or during that
surgery, it makes the recoverymore painful and it actually
leads to other medicalconditions that might develop
into chronic pain, such ascomplex regional pain syndrome.
(25:28):
We have our autonomic system andour autonomic system divided
into sympathetic andparasympathetic systems.
It's at our core as organismsand a lot of times pain and
trauma can get rooted in theautonomic system.
And by treating pain early andaggressively we can decrease the
(25:48):
likelihood that we're going tohave pain for a long period of
time.
There are studies with neonatesthat neonates who don't have
controlled pain, they're notable to express the pain to us,
that they can have changes totheir nervous system as they
develop.
The same thing happens withadults.
We can have pain that changesand my initial injury can be at
(26:11):
my shoulder.
If I don't treat that shoulderaggressively and decrease that
shoulder pain quickly, I mightend up with pain at my hand or
at my wrist.
So I think it's very importantfor us to quickly figure out why
someone is in pain.
It's important to get seen byyour physician, see your
orthopedist, figure out what canbe done and then simultaneously
(26:32):
, I think it's important that ifyou're experiencing that pain,
you need to come in and get seenand we can figure out a joint
plan for how to decrease thatpain and prevent it from
becoming chronic.
Speaker 1 (26:44):
I couldn't agree with you more.
As I alluded to in the past,the concept of preemptive
anesthesia is critical in thesuccessful outcomes of patients'
orthopedic surgeries.
The orthopedic literatureclearly supports that.
Patients going into surgerywith more pain have more pain
coming out of surgery.
So it's incumbent upon us asorthopedic surgeons to do
(27:06):
everything we can to manage thatpatient's pain prior to any
orthopedic procedure.
And in addition to that, whenwe're undergoing major
orthopedic procedures such aship replacement, knee
replacement, shoulder surgeryetc.
We often employ the usage of apreemptive block, a regional
block, by the anesthesiologistwho will block the nerve prior
(27:30):
to surgery so that the patient'sbrain never interprets that
pain signal from the surgicalevent.
In other words, when I'm aboutto perform an incision for a
knee replacement, if that nervethat goes from the brain to the
knee is numbed or anesthetizedby the anesthesial just prior to
(27:50):
surgery, that patient's brainwill never feel the pain from
the surgical incision.
So very often we employ theusage of a regional block or
preemptive anesthesia to helpminimize the patient's pain
after surgery by blocking thenerve before surgery.
And that concept is extremelyimportant in the successful
(28:11):
outcomes of orthopedic surgicalprocedures.
It's not only a regional blockthat's often performed, but
rather it's a multimodalapproach to the preemptive
management of that patient'spain.
So we will often block themorphine receptors in the brain,
for instance with some narcoticmedication.
There will be some localanesthetic which will block the
(28:34):
nerve itself, andanti-inflammatories often can be
given up until surgery as wellto block the inflammation
associated with the surgicalprocedure.
All of this contributes tohaving less pain after surgery
and it's very, very important inthe area of orthopedics and
pain management.
Speaker 2 (28:52):
I couldn't agree more .
In my training we did a lot ofradiofrequency ablation and so
those nerves that you alluded to, prior to a knee surgery, those
nerves can be blocked.
Sometimes if a patient is goingto be having knee surgery or
knee replacement but they mightnot get around to it because
something in their life iscausing it to be delayed, we can
(29:14):
do a radio frequency ablationand provide some relief of their
pain for a number of monthsuntil they're able to have that
knee replaced.
We can do this, as you alludedto, not only with interventions
but with appropriate guidedmedication as well.
So by understanding themechanism of the pain and if the
pain is coming from a somaticnerve receptor or from a
(29:35):
neuropathic agent.
If it's nerve pain, we mightwant to use something like
gabapentin.
If it is coming from the bone,tylenol or Advil can be very
effective.
I find often that Tylenol itselfmight be one of the most
underutilized medications.
A lot of times when I ask apatient, when I'm meeting them,
I'll ask them what have you usedfor your pain?
(29:57):
And people don't really mentionTylenol or Advil.
They go straight to talkingabout gabapentin and tramadol,
and a lot of times that Tylenol.
When I ask them.
I said did you ever take it anddid it help you?
And they said, yeah, you know,tylenol helps quite a bit and
I'll ask how frequently do youtake it?
And they'll mention that they,you know, maybe once a week.
(30:18):
People don't want to take it andthat's because there's a lot of
misconceptions with medicationsabout how much is a safe amount
.
We don't want to overdomedications, we don't want to
use them unnecessarily, but partof my training focused on
understanding the medications,why we would use different ones,
and I'll speak to my patientsabout letting them know how much
(30:40):
they can safely take.
So sometimes it is safe to takemore medication than somebody
is taking.
We're not speaking about opiatemedications.
That's generally not part of mytreatment plan.
There's a time and a place, butthe evidence is showing that
that is not really effective forlong term reduction in pain.
But things like Tylenol, advil,other more specific types like
(31:05):
Celebrex, gabapentin, lyricathere's sometimes one might want
to use one or another and I'llguide my patients about which
one's likely right for them.
Speaker 1 (31:15):
Right.
And the other thing that weshould emphasize is and we're
very fortunate at the KailaOrthopedic Center to be
surrounded by so many expertsthe etiology of pain is clearly
multifactorial, but I think it'simportant to mention and
emphasize that the management ofpain is multi-modal as well.
So at the Kaila OrthopedicCenter we have orthopedic
(31:37):
surgeons, we haverheumatologists, we have
physiatrists, such as yourself,interventional pain management
specialists, but we also havechiropractors and acupuncturists
, massage therapists andphysical therapists.
All of these teammates andhealthcare providers collaborate
with one another to manage ourpatient's pain, because it is
(32:00):
multifactorial and we don't justthrow one dart at the patient's
pain.
We sort of attack it from manydifferent angles with all these
different services that weprovide, because it's so
important to recognize that paincomes from a myriad of
different issues.
And in addition to all of this,sometimes we'll have to refer
(32:21):
the patients back to a mentalhealth counselor as well, or a
psychiatrist possibly for themanagement of their mental
health illnesses and things likethat.
Do you agree with that, drReisman?
Speaker 2 (32:31):
I couldn't agree more .
There's an entire branch ofpsychology, pain psychology and
in physical therapy as well painphysical therapy.
Sometimes a patient when I askif they've done physical therapy
, they'll share.
They did, but it made it worseand that's because they didn't.
They were feeling some pain,but pain psychologists will talk
(32:53):
to the patient about good painand bad pain and what type of
pain is important to feel and ispart of growth and what type of
pain you want to be nervousabout, and our physical
therapists can do that as well.
So when I put in an order forphysical therapy, I'll educate
the patient and I'll documentand communicate to a therapist
or to a chiropractor which typeof therapy I think is best for
(33:15):
that patient and somebody twopeople can have the same back
injury, but they might have verydifferent physical therapy
prescriptions because somebodymight need more strengthening
and somebody might need moreflexibility and pain reduction,
and so it's important to keep inmind the whole picture there.
Sometimes it's important thatpatients' families are included
(33:39):
and then other mental healthexperts as well.
We want to make sure that thepatient's mind and is being
treated, and if they need pain,pain psychologist or
psychiatrist, we'll need tobring them in as well.
Speaker 1 (33:51):
Great, I couldn't agree more.
I think that's one of the mostbeautiful things about our
practice.
I think that, since we haveeverything in house, it's truly
a one-stop shop for all yourorthopedic needs, and I mean
that sincerely.
A lot of our patients will endup seeing five, maybe even
sometimes 10 differenthealthcare providers in our
practice.
It's only because we want tomake sure we attack their
(34:14):
problem from multiple differentangles, because each one of our
experts has a different serviceor a different level of
expertise to the treatment ofour patient's underlying
condition, because it does needto be managed from many
different angles, and we want tomake sure we're not missing
anything, to make sure that weadequately address every single
(34:35):
contributing factor of theirpain.
And so that's.
We're very fortunate to havethe colleagues that we do at our
practice all under one roof tomanage that.
Speaker 2 (34:45):
I absolutely agree.
We've spoken about theimportance of quickly and
aggressively treating pain, andpart of why we can do that so
well at the Kaila OrthopedicCenter is because we have such
efficient communication betweendifferent team members.
A patient can see a physicaltherapist or a chiropractor and,
either during their session ortwo minutes afterwards, come
over to my office and let meknow about an update with that
(35:07):
patient, ask me my thoughts, orsometimes it goes both ways.
I'll ask a colleague, arheumatologist, a chiropractor,
an orthopedic surgeon, I'll askthem what they think about
something that one of mypatients in the rooms are
experiencing and then, on thespot, we come up with a
collaborative approach toquickly and efficiently get that
patient what they need in termsof their healthcare.
Speaker 1 (35:29):
It's important to recognize that if something's
not working, we just have to trya different approach.
We just can't keep doing thesame thing over and, over and
over again, and so that's thebeauty of having so many
different alternatives.
So it's important to recognizethat.
And you know, shift gears ifyou have to, even midstream.
So, Dr Reissman, this has beenan awesome time with you today,
(35:52):
getting to appreciate thedifferent factors that
contribute to patients' pain.
We're so happy to have you.
You're definitely an invaluableasset in the practice, because
we do know how ubiquitous theproblem of pain is, and thank
God for doctors like you thatcan help get our patients out of
pain.
We really look forward tohaving you care for many of our
(36:12):
patients for many years to come.
So thanks so much.
It's been a pleasure speakingwith you today.
Thank you, okay.
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