IMPROVING CHRONIC PAIN PATIENTS QUALITY OF LIFE WITH CUTTING EDGE TECHNOLOGY Jacqueline Weisbein, DO Napa Valley Orthopaedic Medical Group
Who Am I? Avid equestrian Trained in Physical Medicine & Rehabilitation Sub-specialty in Interventional Pain Management History of multiple injuries sports injuries Committed to helping patients improve their quality of life
Disclosures Consultant for: Medtronic Abbott
What is pain? According to Medilexicon s Medical Dictionary: A variably unpleasant sensation associated with actual or potential tissue damage and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors. Each person experiences pain differently. Only the person who is experiencing the pain can describe what they are feeling!
How common is pain? Pain is a very common problem for adults as we age. 1/6 of the population is partially or completely disabled by pain 1 in 20 Americans seek medical care for back pain each year Institute of Medicine (US) Committee on Pain, Disability, and Chronic Illness Behavior; Osterweis M, Kleinman A, Mechanic D, editors. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Washington (DC): National Academies Press (US); 1987. 6, The Epidemiology of Chronic Pain and Work Disability. Available from: https://www.ncbi.nlm.nih.gov/books/nbk219253/
Pain is not a normal part of aging! Although Pain is common, physical pathology and/or psychopathology are always involved (Harkins et al. 1994).
Why are so many people not treated? Many patients go untreated or undertreated for pain. Under treatment can have consequences for pain and can have a negative impact on their health and quality of life. This can result in depression, anxiety, social isolation, cognitive impairment, immobility, and sleep disturbances. Reasons for inadequate pain control include lack of physician training, inappropriate pain assessment, and reluctance to prescribe opioids secondary to fear of addiction.
How do I work them up? History Physical Exam Imaging WHAT TYPE? Conservative treatment: PT, NSAIDS, etc. What does their insurance require for the next level of treatment? https://radiopaedia.org/cases/normal-lumbar-spine-mri
Pain Management or Surgery? Simple procedures before complicated Reversible before irreversible No one ever gets to test out a lumbar fusion and then change their mind if they do not have good relief
What is a Pain Management Physician? We are doctors, either Anesthesiologists, Physiatrists, Neurologists, or Psychiatrists who have done additional training to help patients manage their pain. We can use: 1. Medications 2. Injections 3. Implantable Devices 4. Integrative Therapies 5. Clinical Research Trials
How do I know what treatment is right for my patient? When you refer your patients to be evaluated by a Pain Management physician, we create a comprehensive plan that is unique to each patient. There is NO formulaic way to treat every patients pain.
Conditions Treated Spinal Disorders/Back & Neck Pain Neurologic disorders Peripheral Neuropathy Radiculopathy/ Sciatica Headache Spinal Cord Injury Cancer Pain/ Palliative Care Palliative Care/End of Life Care Stroke with associated pain & spasticity Shingles Dystonia Fibromyalgia Headache Joint Disease/Arthridities Abdominal/Pelvic Pain Post Surgical Pain Complex Regional Pain Syndrome TMJ Disorders Vertebral Compression Fractures Facial Pain
Psychological Effects and Quality of Life Quality of life affected : Loss of employment Marital, family, or social dysfunction General physical and cardiovascular deconditioning
Treatments Offered Evaluation & Treatment Medical Management Epidural Injections Facet Joint Injections & Radiofrequency Sacroiliac Joint Injection Joint Injections Nerve Blocks Spinal Cord Stimulation DRG Stimulation Intrathecal Pump Management Botox Migraine Botox for Spasticity Botox for Dystonia Intrathecal Baclofen Pump Management Prosthetic Management Implantable Device Revisions Kyphoplasty Osteocool
Treatment Continuum
What kind of medications? Antiinflammatories, opioids, adjuvants including antidepressants and anticonvulsants.
Issues with Opiates Proper Dosing Side effects Appropriate Use/Diversion Prescribing guidelines THC/EToH
Types of Injections Facet Joint Injections Transforaminal Epidural Injections Sacroiliac Joint Injections Radiofrequency Ablation
Compression Fracture Treatment
When to consider implantable devices? Inadequate Pain Relief Intolerable Side Effects Simple before Complicated Reversible before Irreversible
Spinal Cord Stimulation
Percutaneous Leads
Dorsal Column vs Dorsal Root Ganglion Stimulation Dorsal Column Stimulator is a type of implantable neuromodulation device that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions of the trunk & extremities DRG stimulation has been approved for the treatment of CRPS, but can be useful for any type of focal neuropathic pain at or below the waist, including: diabetic neuropathy phantom limb pain post-herpetic neuralgia persistent foot, leg, knee, hip or abdominal pain after surgery.
Indications for Neuromodulation Neurostimulation Complex Regional Pain Syndrome Radiculopathies Arachnoiditis Peripheral Ischemic Pain Neuralgias Failed Back Syndrome Neurostim or IT Infusion Failed Back Syndrome CRPS Arachnoiditis Painful Neuropathies Phantom Limb Pain Axial Low Back Pain Intrathecal Infusion Diffuse Cancer Pain Failed Back Syndrome Axial Somatic Pain Osteoporotic comp fx Arachnoiditis Visceral Pain Head, Neck Pain Spasticity
Intrathecal Pain Therapy: Reduced Dosage 1 mg Intrathecal Morphine = 300 mg Oral Morphine
Botox for Chronic Migraines BOTOX for injection is indicated for the prophylaxis of headaches in adult patients with chronic migraine ( 15 days per month with headache lasting 4 hours a day or longer). The most frequently reported adverse reactions following injection of BOTOX for chronic migraine vs placebo include, respectively: neck pain (9% vs 3%), headache (5% vs 3%), eyelid ptosis (4% vs < 1%), migraine (4% vs 3%), muscular weakness (4% vs < 1%), musculoskeletal stiffness (4% vs 1%), bronchitis (3% vs 2%), injection-site pain (3% vs 2%), musculoskeletal pain (3% vs 1%), myalgia (3% vs 1%), facial paresis (2% vs 0%), hypertension (2% vs 1%), and muscle spasms (2% vs 1%). Severe worsening of migraine requiring hospitalization occurred in approximately 1% of BOTOX treated patients in study 1 and study 2, usually within the first week after treatment, compared with 0.3% of placebotreated patients. https://www.botoxmedical.com/chronicmigraine
Understanding Spasticity An abnormal increase in muscle tone caused by injury of upper motor neuron pathways regulating muscles May be caused by injury or disease of the central nervous system A velocity-dependent increased resistance to passive stretch Characterized by exaggerated tendon jerks May be accompanied by hyperexcitability of the stretch reflex
What Causes Spasticity? Theory Imbalance between descending excitatory and inhibitory impulse to the alpha motor neuron: Spasticity of cerebral origin results from lack of descending inhibitory input from subcortical nuclei in the brain Spasticity of spinal origin results from interruption of descending tracts that inhibit or modulate alpha and gamma motor neurons
Spasticity Treatments Botulinum toxin Intrathecal baclofen pump Indications: MS SCI Stroke CP Other Spasticities
Quality of LIFE!
Any Questions? Thank you for your TIME! Jacqueline Weisbein, DO Napa Valley Orthopaedic Medical Group 3273 Claremont Way Suite 100 Napa CA 94558 Office: 707-254-7117 Fax: 707-265-6435 Cell: 954-319-6338 Email: jweisbein@napavalleyortho.com