The PMRExam Podcast

PainExam Podcast Episode: An In-Depth Look at Hydrogen-Rich Water for Chronic Inflammatory Pain

In a recent episode of the PainExam podcast, Dr. David Rosenblum delves into an intriguing study published in the journal Antioxidants, exploring the therapeutic potential of hydrogen-rich water (HRW) in alleviating chronic inflammatory pain and associated mood disorders in mice. The study, conducted by Santiago Coral-Pérez and colleagues from the Institut d’Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, presents compelling evidence supporting the analgesic, antidepressant, and anxiolytic effects of HRW.

Study Overview

The study investigates the efficacy of HRW in treating nociceptive responses and affective disorders associated with chronic inflammatory pain. Using a mouse model induced by the subplantar injection of complete Freund's adjuvant (CFA), the researchers evaluated the impact of HRW on several parameters:

1. Nociceptive Responses: Mechanical allodynia and thermal hyperalgesia.
2. Affective Disorders: Depressive-like behaviors (measured by Tail Suspension Test and Forced Swimming Test) and anxiety-like behaviors (assessed using Elevated Plus Maze and Open Field tests).
3. Biomarker Analysis: Levels of oxidative stress, inflammatory, and apoptotic markers in the paws and amygdala.

Key Findings

1. Analgesic Effects:

• Mechanical Allodynia and Thermal Hyperalgesia: The study found that both intraperitoneal and subplantar administration of HRW significantly reduced mechanical allodynia and thermal hyperalgesia in CFA-injected mice. Remarkably, the local (subplantar) administration showed greater effectiveness, achieving complete inhibition of nociceptive responses with just one day of treatment.

2. Antidepressant and Anxiolytic Effects:

• Depressive-like Behaviors: HRW treatment normalized the increased immobility times in both the Tail Suspension Test and Forced Swimming Test, indicating potent antidepressant properties.
• Anxiety-like Behaviors: HRW also reversed the anxiety-like behaviors in the Elevated Plus Maze and Open Field tests, showcasing its anxiolytic effects without impairing motor function.

3. Biochemical Pathways:

• The study highlighted the significant role of the Nrf2/HO-1-NQO1 pathway in mediating the analgesic effects of HRW. Inhibitors targeting this pathway reversed the pain-relieving actions of HRW, underscoring its pivotal role.
• Oxidative Stress and Inflammation: HRW treatment reduced the expression of oxidative (4-HNE), inflammatory (p-IKBα), and apoptotic (BAX) markers in both the paw and amygdala tissues, demonstrating its broad-spectrum protective effects.

Implications for Clinical Practice

Dr. Rosenblum emphasizes the potential of HRW as a novel therapeutic strategy for chronic inflammatory pain and its associated comorbidities. The study's findings suggest that HRW could offer a multifaceted approach, addressing both pain and mood disorders through its antioxidant, anti-inflammatory, and anti-apoptotic properties.

Conclusion

The episode concludes with a discussion on the broader implications of these findings for pain management, particularly in conditions where chronic inflammatory pain is prevalent. Dr. Rosenblum highlights the need for further clinical trials to validate these promising preclinical results and explore the potential of HRW in human subjects.

For more detailed insights into this study, including potential applications and future research directions, tune into the PainExam podcast with Dr. David Rosenblum.

For more information go to:

https://molecularhydrogeninstitute.org/links-mhi/

Other Announcements from NRAP Academy:

• PainExam App is ready for iphone
•  
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar

 

 

  Ultrasound Interventional Pain Course Registration    For Anesthesia Board Prep Click Here!

References

Coral-Pérez, S., Martínez-Martel, I., Martínez-Serrat, M., Batallé, G., Bai, X., Leite-Panissi, C. R., & Pol, O. (2022). Treatment with hydrogen-rich water improves the nociceptive and anxio-depressive-like behaviors associated with chronic inflammatory pain in mice. Antioxidants, 11(11), 2153.

Dr. Rosenblum serves at AMETD's 2024 Conference as faculty and discusses the safe and accurate usage of Ultrasound to Guide PRP injecitons

Discussed in this lecure:

Knee, Hip, Shoudler, Ligament and Tendon Targets, the ultrasound technique, the evidence for PRP and controversy.  Controversy with respect to the Achilles Tendon!

Other Announcements from NRAP Academy:

• PainExam App is ready for iphone
•  
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar Ultrasound Interventional Pain Course Registration    For Anesthesia Board Prep Click Here!

References  https://rapm.bmj.com/content/rapm/early/2024/07/16/rapm-2024-105593.full.pdf

Disclaimer

Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is  for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

Podcast Show Note Summary:

Episode Title: "New Guidelines for Corticosteroid Injections in Chronic Pain Management"

This podcast is a discussion about the recent review article

Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society

In this episode, we dive into the recently published guidelines on the use of corticosteroid injections for managing chronic pain, developed by the American Society of Regional Anesthesia and Pain Medicine, along with several other prominent pain societies. These guidelines address the safety and efficacy of corticosteroid injections for sympathetic and peripheral nerve blocks, as well as trigger point injections.

Key Discussion Points:

1. Background and Need for Guidelines:

   • Overview of potential adverse events from corticosteroid injections, such as increased blood glucose levels, decreased bone mineral density, and suppression of the hypothalamic–pituitary axis.
   • Importance of using lower doses of corticosteroids, which studies have found to be just as effective as higher doses.

2. Development of the Guidelines:

   • The guidelines were approved by multiple pain societies and structured into three categories: sympathetic and peripheral nerve blocks, joint injections, and neuraxial injections.
   • Extensive literature review and consensus-building through a modified Delphi process.

3. Key Recommendations:

   • The addition of corticosteroids to local anesthetics is recommended for certain nerve blocks, such as the greater occipital nerve block for cluster headaches and ilioinguinal/iliohypogastric nerve blocks for post-herniorrhaphy pain.
   • Corticosteroid addition is not recommended for sympathetic nerve blocks, greater occipital nerve blocks for migraines, and pudendal nerve blocks for pudendal neuralgia.
   • Imaging guidance (ultrasound or fluoroscopy) improves the safety and accuracy of certain procedures.

4. Efficacy and Safety:

   • Detailed analysis of various studies on the effectiveness of corticosteroid injections for different types of chronic pain.
   • Discussion on the minimal benefit of corticosteroids in trigger point injections and the potential risks associated with their use.

5. Clinical Implications:

   • https://form.jotform.com/240446610837052How these guidelines can assist clinicians in making informed decisions regarding corticosteroid use in chronic pain management.
   • Emphasis on the need for personalized treatment plans based on individual patient characteristics and clinical data.

6. Future Directions:

   • Identification of gaps in the current research and the need for well-designed studies to further assess the benefits and risks of corticosteroid injections.

Join us as we explore these comprehensive guidelines and their potential impact on improving chronic pain management practices.

Resources:

• Link to the full guidelines: Journal Online

Other Announcements from NRAP Academy:

• PainExam App is ready for iphone
•  
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar

 

 

  Ultrasound Interventional Pain Course Registration    For Anesthesia Board Prep Click Here!

References  https://rapm.bmj.com/content/rapm/early/2024/07/16/rapm-2024-105593.full.pdf

Disclaimer

Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is  for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

PainExam Show Notes: Mandibular Division of the Trigeminal Nerve Block with Dr. David Rosenblum Introduction

• Host: Dr. David Rosenblum
• Topic: Mandibular Division of the Trigeminal Nerve Block for Cancer Pain Management
• Techniques: Ultrasound and Fluoroscopic Guidance

Overview

• Purpose: Alleviate chronic facial pain, specifically in cancer patients suffering from trigeminal neuralgia or other related conditions.
• Focus: Detailed discussion on the anatomy, clinical presentation, and procedural techniques for effective nerve block.

Anatomy of the Mandibular Nerve

• Origin: Mandibular nerve is a branch of the trigeminal nerve (cranial nerve V).
• Pathway: Exits the middle cranial fossa through the foramen ovale and descends between the lateral and medial pterygoid muscles.
• Sensory Innervation:
  • Anterior two-thirds of the tongue
  • Teeth and mucosa of the mandible
  • Skin of the chin and lower lip
  • Skin over the mandible (excluding the mandibular angle)
  • Tragus and anterior part of the ear
  • Posterior part of the temporalis muscle up to the scalp

Ultrasound-Guided Technique

1. Patient Positioning:
   • Patient lies on their side with the affected side facing upward.
2. Transducer Selection:
   • Curvilinear transducer preferred for deeper structures.
3. Transducer Placement:
   • Place distal and parallel to the zygomatic arch to bridge the coronoid and condylar processes.
4. Anatomical Landmarks:
   • Identify the lateral pterygoid muscle and plate.
   • Use power Doppler to locate the sphenoid palatine artery.
5. Needle Trajectory:
   • Introduce the needle using an out-of-plane approach to target the pterygopalatine fossa (anterior to the lateral pterygoid plate).
   • For the mandibular nerve block, target the area posterior to the lateral pterygoid plate between the medial and lateral pterygoid muscles.
6. Electrostimulation (Optional):
   • Utilize a 22G, 10 cm insulated short beveled needle connected to a peripheral nerve simulator.
   • Position confirmed by motor response from the temporalis and masseter muscles.

Fluoroscopic-Guided Technique

1. Patient Positioning:
   • Similar to ultrasound guidance, patient lies on their side with the affected side facing upward.
2. C-arm Positioning:
   • Position the C-arm to visualize the foramen ovale.
3. Needle Insertion:
   • Insert the needle under fluoroscopic guidance towards the foramen ovale.
4. Contrast Injection:
   • Confirm needle placement with contrast injection.
5. Anesthetic Administration:
   • Administer local anesthetic and/or neurolytic agents.

Clinical Symptoms and Diagnosis

• Symptoms:
  • Unilateral sharp, stabbing, or burning pain in the mandibular nerve distribution.
  • Pain triggered by activities such as eating, talking, washing the face, or cleaning the teeth.
• Diagnostic Imaging:
  • MRI or CT scans to identify causes like vascular compression, mass lesions, or fractures.

Complications and Considerations

• Potential Complications:
  • Bleeding, hematoma, infection, and hypersensitivity reaction to the injectate.
  • Serious complications from neurolytic agents like permanent sensory deficit and tissue necrosis.
• Alternative Treatments:
  • PNS? Radiofrequency or cryoablation for recalcitrant cases.

Conclusion

• Efficacy: Ultrasound and fluoroscopic guidance provide precise targeting of the affected nerves, minimizing collateral damage.
• Safety: Routine use of power Doppler imaging to avoid injury to surrounding vessels.
• Recommendation: Consider these techniques for patients unresponsive to oral medications or unsuitable for surgery.

These show notes provide a comprehensive overview of the discussion, highlighting key points on the anatomy, technique, and clinical considerations for mandibular nerve blocks in cancer patients.

Other Announcements from NRAP Academy:

• PainExam App is ready for iphone
•  
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar

 

 

  Ultrasound Interventional Pain Course Registration    For Anesthesia Board Prep Click Here!

References

Nicholas A Telischak, Jeremy J Heit, Lucas W Campos, Omar A Choudhri, Huy M Do, Xiang Qian, Fluoroscopic C-Arm and CT-Guided Selective Radiofrequency Ablation for Trigeminal and Glossopharyngeal Facial Pain Syndromes, Pain Medicine, Volume 19, Issue 1, January 2018, Pages 130–141, https://doi.org/10.1093/pm/pnx088

Allam, Abdallah El-Sayed, et al. "Ultrasound‐Guided Intervention for Treatment of Trigeminal Neuralgia: An Updated Review of Anatomy and Techniques." Pain Research and Management 2018.1 (2018): 5480728.

 

Disclaimer: This Podcast, website and any content from NRAP Academy (NRAPpain.org) otherwise known as Qbazaar.com, LLC is  for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user’s own risk. Professionals should conduct their own fact finding, research, and due diligence to come to their own conclusions for treating patients. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their health care professionals for any such conditions.

 Join us on this episode of the PainExam Podcast where rising star, Christopher Robinson, MD PhD discusses his upcoming paper on exosomes featuring some of the largest names in pain managment.  Dr. Rosenblum also alludes to degenerative disc disease being a partially infectious podcast.  

Other topics discussed on this podcast:

The Anesthesiology Job Market

Pain Management Fellowship 

Duration of Pain Management Fellowships

Should Pain Management be an Independent Residency?

Other Announcements from NRAP Academy:

• PainExam App almost ready
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar

 

 

  Ultrasound Interventional Pain Course Registration      For Anesthesia Board Prep Click Here!

Journal Club:  Treating Degenerative Disc Disease with Leukocyte Rich PRP

Dr. Rosenblum discusses an article written by Dr. Gregory Lutz describing Leukocyte RIch PRP's role in treating Degenerative Disc Disease and the theory that there is an infectious disease component to disc injury. 

Dr. Lutz describes multiple articles, as well as anectodal experience in which bacterial infectious was demonstrated in pathological discs, and PRP was successful in alleviating symptoms, modic changes and improved clinical as well as radiographic appearance.

Other Announcements from NRAP Academy:

• PainExam App almost ready
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar   Ultrasound Interventional Pain Course Registration      For Anesthesia Board Prep Click Here!

References

Lutz, Gregory E. "Intradiscal Leukocyte Rich Platelet Rich Plasma for Degenerative Disc Disease." Physical Medicine and Rehabilitation Clinics of North America 34.1 (2023): 117-133.https://www.binasss.sa.cr/bibliotecas/bhm/feb23/61.pdf

Dr. Rosenblum reviews an article by Dr. Reuben Ingber regarding the use of iliopsoas trigger point dry needling and therapeutic stretching in the treatement of 6 consecutive patients wiht acute lumbar radiculitis and foot drop.     Other Announcements from NRAP Academy:

• PainExam App almost ready
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar   Ultrasound Interventional Pain Course Registration      For Anesthesia Board Prep Click Here!

References

Reuben S. Ingber, Iliopsoas trigger point dry needling and therapeutic stretching in the treatment of a series of six consecutive patients presenting with acute lumbar radiculitis and foot drop, Journal of Bodywork and Movement Therapies, Volume 36, 2023, Pages 1-4, ISSN 1360-8592,

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57702#:~:text=No%20more%20than%203%20Trigger,group%20are%20not%20billed%20separately.

CMS National Coverage Policy

Dr. Rosenblum describes a patient with chronic shoulder pain who failed shoulder replacement, steroid injections, nerve blocks, cryotherapy, and peripheral nerve stimulation of the axillary and suprascapular nerve block.  In this podcast, he discusses his perfomance of Shoulder Radiofrequency Ablation targeting the articular branches of the suprascapular nerve, axillary nerve, nerve to subscapularis and lateral pectoral nerve.   Reference: https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2020/11/01/how-i-do-it-shoulder-articular-nerve-blockade-and-radiofrequency-ablation   Other Announcements from NRAP Academy:

• PainExam App almost ready
  •  Pain Management Board Prep migrated to NRAPpain.org
• AnesthesiaExam Board Prep migrated to NRAPpain.org
• PMRExam Board Prep migrated to NRAPpain.org

  Live Workshop Calendar Ultrasound Interventional Pain Course Registration      For Anesthesia Board Prep Click Here!

Advocating for Transparency and Oversight in Pain Management

Introduction:

• Welcome back to Painexam, where we delve into the latest advancements and challenges in pain management.
• Today's episode highlights a significant advocacy effort made by leading Interventional Pain Physicians and industry experts.

Summary of Lobbying Effort:

• On March 20, 2024, a group of widely known and respected pain physicians and industry leaders, including Drs. Sean Li, Peter Staats, Mehul J. Desai, David Reece, Hemant Kalia, and David Rosenblum, alongside industry figures Mark Stultz, Christopher Conrad, and Cecelia Ruble, visited Capitol Hill to advocate for greater oversight and transparency in independent review organizations.
• Despite their busy schedules, they recognized the critical need to address the 0% turnover rate in appeals for denied treatments, which disproportionately affects patients seeking alternatives to surgery and opioid medication.

Importance of Transparency:

• The issue extends beyond pain management, impacting patients across various medical fields.
• While opioid therapy may seem economically favorable initially, the long-term consequences, including delayed care and medication side effects, often outweigh the costs.
• The group emphasized the importance of an unbiased review for  accessible, cutting-edge treatments to improve patient outcomes and reduce overall healthcare expenses.

Purpose of the Lobbying Effort: Contrary to pushing any specific company agenda, the initiative aims to highlight the challenges patients and physicians encounter in securing optimal treatment outcomes.

 

For Board Prep, Ultrasound Training and more, visit:

Dr. David Rosenblum, a pioneer in interventional pain medicine, particularly in ultrasound-

guided procedures and regenerative pain medicine, underscores the necessity of addressing these issues for the benefit of countless patients suffering from chronic pain.

Conclusion and Actionable Steps:

• To schedule a consultation with Dr. Rosenblum, patients can visit www.AABPpain.com or contact the Brooklyn Office at 718-436-7246 or the Garden City Office at 516-482-7246.
• Stay tuned for more updates on advancements and advocacy efforts in pain management.

Outro:

• Thank you for joining us on this episode of Painexam. Be sure to subscribe for future discussions on navigating the complexities of pain management.

Dr. Rosenblum interviews West Viriginia Society of Interventional Pain Physician's President Rudy Malayil, MD and discusses the upcoming WVSIPP meeting in April 2024 as well as Dr. Rosenblum's upcoming ultrasound course. 

Rudy Mathew Malayil, M.D., completed his internship in General Surgery at New York Presbyterian/Cornell Hospital in New York City, followed by residency training in Physical Medicine and Rehabilitation at New York University Medical School. Dr. Malayil further completed a Pain Medicine Fellowship at the Albert Einstein School of Medicine at the Beth Israel Medical Center Campus in New York City. 

After training he went settled in West Virginia and eventually became the president of West Virginia Society of Interventional Pain Physicians and started private practice Pain Management 360.

https://pain360.org https://www.malayilmd.com   Ultrasound Interventional Pain Course Registration      For Anesthesia Board Prep Click Here!   References https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1293358/full