NOMA 2019 –Las Vegas August 2, 2019 Mgmt_Up… · •PRP prolotherapy: Platelet –Rich Plasma...

UPDATE ON CHRONIC PAINMANAGEMENT

John DiMuro, DO, MBA

Anesthesiology & Pain MedicineDiMuro Pain Management

Reno & Las Vegas NevadaDiMuroPainManagement@Gmail.com

NOMA 2019 – Las VegasAugust 2, 2019

Prevalence of Pain

How Big is the Problem?

• 100 million Americans suffer chronic pain

• Chronic pain is the #1 cause of disability in the US

• A leading cause of prescription drug abuse

So, someone comes to see you with

complaint of pain and you have verified

the source

1) What are your pain management treatment options?

PAIN MANAGEMENT OPTIONS

1) Rest

PAIN MANAGEMENT

OPTIONS1) Rest2) ICE

PAIN MANAGEMENT

OPTIONS1) Rest2) ICE3) OTC

PAIN MANAGEMENT

OPTIONS1) Rest2) ICE3) OTC4) Rx Meds

• Opioids• Muscle Relaxants• Anti-neuropathic • Anti-depressants• NSAIDS• SAIDS• Alpha agonists• NMDA blockers

AB474 Opioid Bill –UpdateRelease of Prescription Pattern Data

• 37% decrease in opioid rx’s

• 54% decrease in opioid & BZD prescribed together

• 44% decrease in rx’s for those who took >90MMeq daily

• 90-day rx’s decreased by 52%

PAIN MANAGEMENT

OPTIONS1) Rest2) ICE3) OTC4) Rx Meds5) Bracing

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates

OTHER OPTIONS

• Topical Preparations (not covered by Medicare)• Acupuncture• TENS unit• Biofeedback / Behavior modification• Laser therapy

WHAT IF NO IMPROVEMENT?

• Advanced non-surgical treatment options vs. surgery?– Can you “fix” the pathology without

surgery?• Disc herniation vs. Disc Tear• Tendon avulsion vs. tear• Cartilage erosion vs. ‘bone-on-bone’ pathology• More advanced conditions?

What will you do for this patient?

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids3) Viscosupplementation

PAIN MANAGEMENT

OPTIONS1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids3) Viscosupplementation4) REGENERATIVE THERAPIES

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids3) Viscosupplementation4) REGENERATIVE THERAPIES

What are Regenerative Therapies?

Per NIH: Regenerative medicine is abranch of translational research in tissueengineering and molecular biology whichdeals with the "process of replacing,engineering or regenerating human cells,tissues or organs to restore or establishnormal function”

History of Regenerative Therapy

• Appears to be credited to osteopathicsurgeon Dr. Earl Gedney the 1930’s. He usedit on his thumb which he injured in amalfunctioning operating room door. Heinjected ‘ irritating ’ solutions into the areawhich ultimately gave him function back. Hesubsequently published multiple studies fromthe 1940’s through the 1960’s on the efficacyof proliferative therapy with dextrose, sarapin,and morrhuate.

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids3) Viscosupplementation4) REGENERATIVE THERAPIES

Regenerative Therapy Terms

• Prolotherapy: Abbreviated term for proliferative therapy. Works locally by increasing growth factor levels for tissue repair using any inciting agent.

• PRP prolotherapy: Platelet –Rich Plasma proliferative therapy. A natural source of growth factors and cytokines/chemokines

• Stem Cells: (1)Embryonic (prenatal) – able to transform into any type of tissue; (2) Adult (postnatal) – able to maintain hemostasis and can be regenerated in a tissue or organ.

PAIN MANAGEMENT

OPTIONS

1) Rest2) ICE3) OTC4) Rx Meds5) Bracing6) Physical Therapy7) OMM/Chiropractic8) Massage Therapy9) Yoga/Pilates10) INJECTION TREATMENTS

1) Local Anesthetics2) Steroids3) Viscosupplementation4) REGENERATIVE THERAPIES

Regenerative Therapy Terms

• Autologous: From the same organism

• Allogenic: Being genetically different (but same species)

• Allograft: A tissue graft from a donor genetically unrelated to the recipient

NON-SURGICAL TREATMENT OPTIONSAnti-inflammatory, pain relief & Rehabilitation

Options

• Steroid injections• Physical Therapy• Chiropractic• OMM• Acupuncture• Yoga/Pilates• RF ablation• Viscosupplementation

Regenerative Treatment Options

• Dextrose Prolotherapy• PRP prolotherapy• Stem cell prolotherapy• PRP + Stem cell Prolo

APPROPRIATE CANDIDATES FORREGENERATIVE THERAPIES

• Surgical refusal• High-risk surgical candidates• Mild to moderate functional loss with

pain complaints

EXAMPLES OF COMMON CONDITIONS THAT MAYRESPOND TO PROLIFERATIVE/REGENERATIVE

THERAPY

• Ligament, muscle and tendon injuries• Degenerative Joint Disease / Traumatic events including labral tears and meniscus issues• Nerve injury• Intervertebral Disc Disease• Spinal Fusion

MSC’s

Multi-lineage differential potential

of MSC’s.

Harvesting Adipose Tissue for MSC’s

How is the procedure performed?

PRP• Sterile blood draw

• Specimen placed in Centrifuge

• Aspiration of the low-volume, high-density cells

• Injection into the pathological area, preferably using US or fluoroscopic guidance

Stem Cell• Harvest sample from bone

marrow or adipose

• Decanted by gravity or slow centrifuge

OR

•Use allogenic cellsTHEN

Injection into the pathological area, preferably using US or fluoroscopic guidance

HOW LONG UNTIL A RESPONSE

IS SEEN?

• Pain relief may occur at any time

• Tissue repair within 1-12 monthsdepending upon type of pathology

CASE STUDY: Pain Physician 2008 by C Centeno, MD

MSC’s harvested from iliac crest and injected into a degenerative knee joint with thinning of the meniscus. 22 MM cells counted and injected into the knee joint

RESULT:

VAS deceased and ROM increased AND…

Results at 6 months

Increased cartilage surface volume

Increased meniscal volume

RISK VS. REWARD

PRO

• Non-surgical option

• Minimally invasive• Able to repeat &

replicate

• Easy to perform• Non-steroid treatment

CON

• Cash pay

• Procedural risk• No guarantee of result

• May have to repeat to optimize treatment

Personal Case Study

Presenting Symptoms

• Hip labrum tear – told she needs surgery

• Painful squat and lunge

• Pain with forced hip flexion

• Decrease in ROM

• Groin pain with ambulation

• Buttock pain when sitting

• Proximal, lateral hip pain

• Unable to perform ADL’s without pain

Determine appropriate regenerative option (how big of a response do we need/want?)

Average case

• Dextrose Prolotherapyvs.

PRP

Advanced case

• Stem cell prolotherapy

My decision: HD-PRP

• Two treatments in 4 days due to logistics• Only necessary physical activity for 4weeks

Fluoroscopic Image - Hip

Fluoroscopically-guided hip joint injection needle position

What if you don’t use fluoroscopic guidance?

Fluoroscopically-guided hip joint injection needle position with contrast

RESULTS

4 weeks post-procedure

Complete resolution of her pain

MRI 6 months later demonstrated no labral tear per radiologist

Happy Patient!

Karen at 6 mo

PAIN MANAGEMENT OPTIONS

(1) Early referral to advanced pain specialist for evaluation

(2) Make sure you have an evidence-based diagnosis (pathology on imaging study)

(3) Discuss risk vs. reward of treatment options including cost

NOMA 2014TAKE HOME POINTS1) There really are non-surgical therapeutic treatments

for even some advanced musculoskeletal pathologies

2) Obtain evidence before blindly referring out

3) Be knowledgeable about innovative treatment options

4) These treatments can be done painlessly with low risk and have little to no recovery time

5) Worker’s Comp has covered these treatments here in Reno

Thank you

Questions?

UPDATE ON CHRONIC PAINMANAGEMENT

John DiMuro, DO, MBA

Anesthesiology & Pain MedicineDiMuro Pain Management

Reno, Las Vegas & Pahrump, NevadaDiMuroPainManagement@Gmail.com

NOMA 2019 – Las VegasAugust 2, 2019