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UPDATE ON CHRONIC PAINMANAGEMENT
John DiMuro, DO, MBA
Anesthesiology & Pain MedicineDiMuro Pain Management
Reno & Las Vegas [email protected]
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, [email protected]
NOMA 2019 – Las VegasAugust 2, 2019
