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Tell Me Where It Hurts: Pain Management Specialists Offer Approaches for Alleviating Chronic Pain

Nov 18, 2020, 23:04 PM by Sansum Clinic

Everyone experiences pain at some point. It is one of the most common reasons patients see doctors. Pain often resolves on its own or with standard treatment. But when it persists longer than expected or it is severe, primary physicians may refer patients to pain management specialists. Sansum Clinic recently opened its Pain Management Department that provides patients who suffer from chronic pain with established first-line treatments as well as advanced techniques that represent the leading edge of medical innovation and emerging technologies. Interventional pain management specialists Graham Reimer, M.D. and Emanuel Zusmer, M.D. lead the department, supported by Cori Wright, N.P. and an experienced staff of medical professionals.

One of the typical ways people relieve pain is to take a pill. Options range from familiar over-the-counter tablets to strong prescription painkillers including oxycodone, hydrocodone, and fentanyl. Many of these medications are synthesized to resemble opium-derived drugs such as morphine and heroin. Dr. Reimer advises that while opioid medicines can be relatively safe and effective when managed in a controlled fashion by a physician, they also pose risks including addiction and overdose.

“There is a role for opiates in a medical setting if monitored appropriately in specific circumstances,” he explains. “But our hope is to minimize or eliminate the need for them by providing patients with safe and effective multimodal pain control procedures. We want to avoid the downstream effects of opioid medications while providing solutions that enable patients to live a more satisfying life with less pain.”

Dr. Reimer says the vast majority of issues that stem from minor injuries will get better on their own within six weeks. If pain persists beyond the expected healing period, then it may be appropriate for intervention by a pain management specialist. If it persists beyond six months, it is defined as chronic pain and is typically when patients become candidates for more aggressive treatments including injections and advanced procedures.

Interventional Pain Management

Dr. Zusmer says the goal is to break the cycle of pain. “Often when people experience pain that does not get better over time, they fall into a downward spiral that involves indefinitely taking pain pills and limiting activity,” he says. “That can lead to increasingly higher doses of medications, further disability, and lack of function. As interventional pain management doctors, we focus on procedures that target a specific painful area at the source of pain, therefore avoiding or minimizing the need for strong medications that can have a negative side effect profile or abuse potential.”

Multimodal or multidisciplinary pain management encompasses a variety of treatments. The three main goals are less pain, improved function so patients can return to normal activities, and less medications that may be harmful in the long term. “Most of our patients are in the 60-plus age range and have tried conservative first-line therapies through their primary physicians,” Dr. Zusmer says. “We treat age-related osteoarthritis, musculoskeletal conditions, shoulder and knee pain, bursitis, neck and back pain, radicular pain caused by irritation of a nerve root where it connects to the spine, sciatica caused by a herniated disk of the lumbar region of the spine, and other chronic conditions. It’s not uncommon for us to also treat younger patients including those in their twenties and thirties who have chronic pain-related issues.”

Regarding medication management, first line therapies often include non-opiate anti-inflammatories, nerve pain medications, and muscle relaxants. The goal of steroid based procedures is to use real-time imaging modalities such as fluoroscopy (X-ray) to target medication to a very focused area to reduce inflammation and pain, thereby avoiding some of the detrimental effects these medications may have. Additional treatments could include referrals to physical therapy, chiropractic care, and acupuncture. Psychotherapy can help with depression, anxiety and other comorbid conditions that often accompany chronic pain. For patients who do not experience satisfactory results from first-line therapies, innovative techniques that represent the latest advances in medical technology can be performed.
Innovative Advanced Techniques

The field of pain management is evolving rapidly, with significant research spawning new interventional approaches to managing pain. The latest methods apply modern medical technology and knowledge to provide solutions that can be very effective. Patients who are candidates for these techniques are typically referred to Sansum Clinic’s Pain Management Department by a physician.

Neuromodulation: turning down the pain signals

One of the most robust and promising techniques is neuromodulation, which uses electrical stimulation of the spinal cord to reduce the volume of painful signals that enter the central nervous system. A small computer system and specialized leads that send electronic impulses through the body are surgically implanted under the skin. Waves of energy modulate the nerves to reduce pain. Patients can test to see if neuromodulation will help them before they have the device implanted. This is all done in an outpatient setting with minimal recovery time.

Recently, new frequencies and wave patterns have revolutionized the practice, making it more effective and accessible. Under the supervision of a medical technician, patients can try various wave forms to determine which frequencies work best for them. The most common application of neuromodulation is to treat sciatica and radicular back and leg pain. Earlier methods used low frequencies that mask painful signals, the way rubbing a stubbed toe activates non-painful pathways that disrupt pain sensations. New techniques use specialized high-frequency wave forms to mimic signals that instruct the body to release chemicals that help alleviate pain.

“For the right patient and the right indication, we see a very high rate of success with neuromodulation,” Dr. Reimer says. “Generally, these are people who have already tried the more conservative methods without beneficial long-term results.”

Vertiflex: minimally invasive treatment for spinal stenosis

Vertiflex is a minimally invasive treatment for mild to moderate lumbar spinal stenosis (LSS), which is narrowing of the canal through which the spinal cord runs in the lower spine. The most common symptom of LSS is neurogenic claudication (nerve-related leg pain and weakness) and can also include pain and numbness in the lower back and hips. Previous treatments involved laminectomy surgery, which required a large incision to facilitate the removal of the posterior arch of a vertebra. Patients required months to heal.

Vertiflex can provide effective long-term relief from the pain associated with LSS without major surgery. A small spacer is placed inside the spine without removal of any nearby bone or tissue. The spacer opens the central canal, which keeps pressure off the nerves that cause leg and back pain to help alleviate the symptoms. The outpatient procedure takes about 20 to 30 minutes and can be reversable.

Peripheral nerve stimulation: long-term pain control

Peripheral nerve stimulation is similar in concept to spinal cord stimulation, but it is more targeted. Doctors identify specific peripheral nerves that cause painful issues and apply an electrical current to that nerve to modulate it. The practice can involve an implantable permanent device or a temporary device that the patient wears for a month or two. In many cases, long-term effects for pain control can continue after the device is removed.

Ultrasound imaging: accurate targeting and diagnostics

Ultrasound is a real-time imaging technique that allows doctors to see soft tissue structures in real time. One way it is used in pain management is to assist with nerve block injections. Ultrasound helps doctors identify a specific muscle or nerve tissue area that is causing problems, with a high degree of accuracy. They can then target that specific site with local anesthetic and steroids. This is typically performed on patients who have bursitis or chronic joint pain as a result of degeneration such as in the shoulder, knee, or hip.

Radio frequency ablation: non-surgical alternative to steroid injections

Used in combination with X-ray or ultrasound imaging, radiofrequency ablation heats nerves to cause a thermal lesion that reduces pain signals. X-ray or ultrasound imaging enables doctors to accurately locate nerve tissues that cause pain. Using radio waves, they heat the tip of a needle to dissipate the nerve tissue. This process interrupts the ability of that nerve to send painful impulses. It is an alternative practice to repeatedly injecting an area with anesthetics and steroids, the cumulative effects of which may be detrimental to a patient’s health over time. The outpatient procedure takes about 30 minutes and does not require general anesthesia. Pain relief usually lasts about one year.

Sphenopalatine ganglion block: relief from chronic refractory migraines

Patients who suffer from chronic refractory migraine headaches and do not benefit from medications may be appropriate candidates for sphenopalatine ganglion (SPG) block. In the minimally invasive procedure, doctors apply local anesthetic to the sphenopalatine ganglion, which is a group of nerve cells at the posterior aspect of the pallet that has connections to the brainstem where migraine attacks may be generated. The anesthetic resets the nerve area that transmits painful stimuli. Doctors access the SPG area through the patient’s nose.
“An SPG block can provide long-lasting pain relief from migraines,” Dr. Zusmer says. “It is fast and easy to do, and is low risk with a potential for high reward. I treated a family physician who experienced chronic migraine headaches that were poorly controlled with Botox. He had also tried antibody medications with little success. I performed an SPG block. When he returned for his first follow-up appointment, he told me that it was the most effective treatment he’d ever had. And for the first time in his life, he did not have a headache.”

Kyphoplasty: treatment for vertebral compression fractures

Kyphoplasty is a surgical procedure to treat vertebral compression fractures. It can reduce pain and increase mobility. It is a way to not only stabilize the fracture, but also to help restore the height of the vertebral body. With a compression fracture, the vertebral body is compacted and loses its height. Because of that, the patient’s posture can get deformed and they stoop forward. A specialized balloon-like device is placed into the compression fracture. This procedure restores the normal height of the vertebral body and helps treat the pain from the fracture.

Patients don’t always present an identifiable cause, but often it is the result of a fall or trauma. “Age plays a factor as elderly patients’ bones become more brittle,” Dr. Zusmer explains. “They develop osteopenia and osteoporosis, and that makes them predisposed to these types of fractures.” The hour-long procedure is performed in a hospital setting. The doctors at the Sansum Clinic Pain Management Department are currently developing protocols that will enable them to offer this procedure in the future.

Expert Staff Provides Exceptional Care

Dr. Reimer earned his M.D. at University of Davis in California. Dr. Zusmer earned his M.D. at University of Miami, Miller School of Medicine in Florida. Both doctors are certified with the American Board of Anesthesiology. “Anesthesiology has become the standard background for pain management, especially as the practice has transitioned over the years from oral pain medication treatments to the realm of intervention,” Dr. Reimer explains. “Many of today’s interventional pain management procedures developed out of the anesthesia field, which is why the majority of pain management physicians are anesthesiologists by training.”

Nurse Practitioner Cori Wright assists the doctors at the department in a team-based approach to care. She was trained and certified at Pennsylvania State University School of Nursing. Ms. Wright is involved in follow-up and management of patients over time. She prescribes and manages medications, physical therapy and other physical modalities, and evaluates patients’ progress following the various treatments and procedures they receive from the doctors at the department. She has worked in the neurosurgical field as well as the pain management and addiction domain.

Department staff also includes two medical assistants, two front-office professionals, and a billing and insurance specialist.

Dr. Zusmer says one of the reasons he transitioned from anesthesia to pain management is because it is such a rapidly-evolving field. “The skills and tools available for care are constantly advancing,” he says. “We want to continue to progress in our application of innovative techniques that help patients within the community gain control of their pain. Our goal is to expand our ability to help patients through a complete multimodal approach to treating chronic painful disorders.”

“We are a good central hub to treat people who have painful issues, even if those issues have been addressed before and have become long-term conditions,” Dr. Reimer adds. “For people who are looking for further steps they can take to help with pain, we can diagnose and treat many disorders and refer them to additional resources they may need.” R

Sansum Clinic’s Pain Management Department is at 3916 State Street, Suite 300, in Santa Barbara, California. For more information or to schedule an appointment, please call (805) 681-8901.