Seeking Relief From Chronic Pain

More than 20% of American adults suffer from chronic pain, defined as persistent pain that lasts at least six months.  Back pain, arthritis, nerve pain and headaches are common causes. What can be done when long-term pain is ruining your quality of life?

Host, Jonathan Fialkow, M.D., explored this complex and frustrating syndrome with a panel of experts in a recent episode of Baptist Health's Resource Live program. 

Guests:

• Seif Elbualy, M.D., director of interventional pain management at Baptist Health's Marcus Neuroscience Institute
• Lijo Jose, M.D., a family medicine physician with Baptist Health Primary Care
• Francisco Garcia, a physician assistant at the arthritis clinic at Baptist Health Orthopedic Care

Transcript

Announcer:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely, practical health, and wellness information to improve your family's quality of life.

Dr. Fialkow:

Welcome Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac Investment Institute, where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health. No one goes through life without experiencing pain from time to time. Pain is part of the body's defense system. It can warn us to stop doing something that can cause an injury. Pain usually fades as an injury heals, but according to the US Centers for Disease Control and Prevention, more than 20% of American adults suffer from chronic pain.

Dr. Fialkow:

This complex and frustrating condition was a subject of a recent episode of Baptist Health, resource live program, which I had the pleasure to host. My guests were Dr. Seth Elbualy, who's the Director of Interventional Pain Management at Marcus Neuroscience Institute, part of Baptist Health, Dr. Lejo Jose, a family medicine physician with Baptist Health primary care, and Francisco Garcia, a physician assistant at the arthritis clinic at the Miami Orthopedic and Sports Medicine Institute at Baptist Health. Let's hear what they had to say. Let's kick it off, Seth, with you. Let's start with the basics. What the difference in some chronic pain and other kinds of pain?

Dr. Elbualy:

Chronic pain, there's a varying definition of it, but essentially pain for greater than three months or greater than six months. It's not acute pain. It's not twisting your wrist, for example, and it's ongoing and it can be progressive and debilitating.

Dr. Fialkow:

Any patterns to the kind of pain?

Dr. Elbualy:

It depends on the individual. Oftentimes they have chronic low to moderate pain that spikes or flares with certain activities or certain length of time.

Dr. Fialkow:

Lejo, let's start over to you. We know that someone could get an injury and pain can go away. Let's start with the medical aspects of someone with chronic pain. What are the signs or symptoms of someone with pain that might signal someone should get looked at and specifically can chronic pain be a sign of other medical problems? An injury, so to speak, we could identify what caused it. When people have chronic pain, otherwise, what are the kind of things that you would look for where someone should be aware of?

Dr. Jose:

So chronic pain can be seen in many different ways. It's pretty much either we know if there's a originating cause. It could be something like arthritis, cancer pain that we know where it comes in, it's just not going away after three months. But other things can also leave us prone to having chronic pain. Sometimes it's an old injury and essentially our body has changed in terms of how we perceive pain and we're still feeling it after a little while. So it's our job as primary care physicians to really just kind of try to identify if we can find a root cause for it that we can possibly help manage.

Dr. Jose:

And if not, we have to kind of just figure out what the pain is causing and essentially how to manage the effects of that pain, whether it's the anxiety, the depression, the fatigue they feel from it. Most of these patients they'll feel it in a bunch of different ways. It could be aching, it could be burning, it could be from the nerves. So it's very vague. But whenever you come to your primary care we really want to just assess where it is, how it's affecting you, how it's changed and what things are helping and what things are making it worse.

Dr. Fialkow:

So an injury, a joint or orthopedic problem. And we'll ask Francisco about this in a second. People generally could say, I'm in pain because I fell or did this or hurt this, where would be more common causes or findings you see when it's not joint related, it's throughout there, for example, cancer pain. Do, do you mean people with cancer can develop a pain syndrome or can someone present with a pain and turns out that it's caused by cancer?

Dr. Jose:

Well, different injuries and diseases can also, they cause changes to the body that leave them more sensitive to pain and, these injuries and diseases that we have, we might not always recognize them while we're having them, but they do because these patients have been feeling pain for some length of time, which is greater than three months, there's something has changed in the body and it's our job. So when we can't see it pretty much overtly in terms of an injury, we start looking for things like, is it a nerve pain? Is there something in a body that's creating this extra sensitivity, the pain. And that's when we really order different tests and different diagnostics to make sure everything else is optimized in a body and to see what's left.

Dr. Fialkow:

So I think the take home point going forward, certainly if someone feels pain, they want to get assessed and treated so they're not in pain, but we also want people who have a chronic pain to see the primary care doctor to make sure the pain is not coming from something else. That could be a concern. So I think it's both ways of approaching it, which is well said, Francisco, from an orthopedic standpoint. Sure. You see a lot of acute pain as well as going back to the chronic pain. Where do you see more of the, is there a pattern to the orthopedic causes of chronic pains? Are there some joints, for example, that might be more contributed to chronic pain or kinds of people, that medical conditions that might lead towards a higher likelihood of chronic pain. Do you see any patterns from the orthopedics?

Francisco Garcia:

Oh, definitely. So one of the most common conditions, chronic conditions that I see here in the clinic is happening. Arthritis. We have about 53 million Americans today, living with arthritis in their joints. That means one out of four Americans complain of one or multiple joint pain, which can be acute or they can be chronic. The majority of them are chronic because they've been lingering. Dr. Seth had mentioned for more than three to four, six months, even greater. Sometimes it's an exacerbation of the preexisting condition that causes the pain to intensify. So the way that I normally describe arthritis and pain to the patients here is we have three different types of, we have about a hundred type of arthritis. So the easiest way to differentiate them is osteoarthritis inflammatory arthritis and posttraumatic arthritis. Meaning osteoarthritis is the most common effect. Approx 2.5 million Americans while the other two are less posttraumatic arthritis, just to give a brief information is secondary after a trauma to the joint and inflammatory arthritis and osteoarthritis are more genetics,

Dr. Fialkow:

Osteoarthritis. It's also more of degenerative process, right?

Francisco Garcia:

Correct. This is a degenerative process that can occur at any age. I mean data right now states that people even in their early thirties can actually have osteoarthritis disease, because it comes from a genetic condition.

Dr. Fialkow:

Do you see any patterns in the people who might have more arthritic type of causes of chronic pain?

Francisco Garcia:

Well, arthritis doesn't really discriminate or age group of social economics or the type of that activities or, or their BMI. There's definitely a lot of influence on overweight patients and patients who participate on high impact activities, such as long distance runner. So definitely takes a toll on their joints.

Dr. Fialkow:

Now let's get into, I think the meat of it, which is probably more what we can offer people who have chronic pain and syndrome. So Seth, let, let's start with you as a leader in interventional pain management, obviously chronic pain can limit people. Can you speak a little bit about when people come to you, what's the main reason in terms of activity limitations, and then what are the kind of options that can be offered to people who have chronic pain syndromes?

Dr. Elbualy:

So most of our patient population here is elderly and we have a lot of back pain related or spine related conditions. Certainly spinal stenosis is a big player in this population. We also have younger people with more acute disc herniations and such causing spine related pain. So the key part is they all get some sort of imaging or they've had it before that they've seen us and physical exam to determine does their pain complaint match their physical exam? Does it match their imaging to really figure out what's the best sort of treatment for them.

Dr. Fialkow:

How, how go on? So, to that end, when you do your assessment and obviously everyone's individualized is a treatment plan based on the person. Again, their subject of I'm in pain, I one pain, is there a threshold that it's, I can't do something. And if that's the case, what are the more common things that people can't do? And let's start with the population. You're talking about an older population, let's say with spinal stenosis. What are the, what are the early signs of that? And what are the li how does that limit people?

Dr. Elbualy:

Usually they're limited in the amount they can walk. So, oh, they get essentially a claudication or they get increased back pain or leg pain as they walk. Oftentimes they have to walk with a walker or shopping cart, leaning forward, these, these kind of things where they have to stop every 50 to a hundred feet. And it really varies depending on the individual, their pain threshold, et cetera. Sometimes they can't even stand for more than five to 10 minutes without having to sit down. So those are the big complaints we see in the, in the older population. Younger people are complaining that it's hard to stand at work or perform at their job. And also they won't want to do sports essentially.

Dr. Fialkow:

So go through a little bit. The treatment options maybe ranging from the younger person who has some say, back pain while standing to the more severe conditions. What are the treatment options that you offer, obviously, as you mentioned, gauge towards the person's pain, tolerance and their own limitations, but run through the gambit of a little bit of what you would offer.

Dr. Elbualy:

So it's a little different for us because we're almost like a tertiary care sort of specialty. So most people have already kind of gone through their primary, seen orthopedics, even seen neurosurgery before they see me. But in general, conservative treatment first and conservative treatment is things such as physical therapy, body conditioning, core strengthening, all these kind of things, medications with anti-inflammatories if appropriate. Once they sort of fail these kind of initial treatments, usually that's when they're coming into our door and say, what, what interventional things can we do to increase your function in your quality of life? And, and that varies from simple injections to things like ablation treatments, where we ablate nerves to joints up to including the spinal cord stimulation.

Dr. Fialkow:

So a real spectrum of things you'll offer people from depending on how limited they are and how much pain in they're in, I'm listening to you, and from personal experience, I was having lower back pain walking for long periods of time, went through the usual workups found, it was a generic condition recommended for physical therapy and then core exercises. And you know what Seth, they actually work. I mean, it's fascinating. I mean, it really relieves the pain. And of course, when I don't do it for a period of time, it comes back and I have to do it again. But Francisco back towards the arthritis and treatments now. So what do you see in your practice and with the Miami Orthopedic Sports Medicine Group? What are the things that we can offer people for those joint complaints, those arthritic complaints, Seth mentioned about chronic back pain, the general spine conditions, et cetera. What do you see for the other joints, the hips and the knees and maybe shoulders.

Francisco Garcia:

So in the clinic, we focus on the nonsurgical treatment for Neo hip arthritis in the United States, we do approximately one million hip and knee replacements per year. That's not counting shoulder replacement, elbow replacement, et cetera. The clinics we focus on here is a nonsurgical management.

Francisco Garcia:

Patients who have arthritis, not necessarily needs to proceed with joint replacement surgery. The majority of them can be treated there symptoms based on evidence based treatments that has show to help reduce the pain, the inflammation, and restore the function back to the patient's need. Most of the things that we do here at the clinic is physical therapy, lifestyle modification, education of the patient's condition, weight reduction. And we talked about in knee injections, oral and inflammatory, etc.

Dr. Fialkow:

In other words, is there a stepwise approach or again, very individualized.

Francisco Garcia:

Yes. This is definitely a stepwise approach. And obviously you also tailor the treatment based on the patient's condition. What had been done before, am I dissect or third opinion? Have they done physical therapy in the past? And if they did it 10 years ago, then it's worth trying to repeat the physical therapy again, because if they haven't done anything for the past eight, nine, ten years.

Dr. Fialkow:

And you mentioned surgery is an option, is there ever a situation where you or your colleagues will look at someone and say, you know what, it just ain't going to work. You need a replacement. Or is that always a result of other process, the result after other interventions have failed?

Francisco Garcia:

Well, it also depends on the patients, how much this is affecting their activities of living, how much they're affecting their quality of life, just because a patient shows up to the clinic and we get x-rays and their bone and bone doesn't mean necessarily they need to proceed with surgery. Maybe that patient is very low demand. Maybe has a lot of comorbidities and may not benefit from surgery at this time. Maybe they benefit more from nonsurgical management. If you can meet that, then you help that patient.

Dr. Fialkow:

And, I think that's great. That's what Seth brought up as well. And as well as Lejo, it's a customized approach. People should not have to go in with a preconceived notion of what they need and what they're going to get. Talk to the doctor, get the evaluation and create that treatment plan. That's unique to your situation and your desires, what you want out of the treatments. Seth, actually, let me pull it back for a second. I mean, you're an anesthesiologist and director of interventional chronic pain management, let the viewers know a little bit about what's the unique aspects of the anesthesiology training and skill sets that puts you in that role. What can be offered as an anesthesiologist in this role that makes it unique?

Dr. Elbualy:

Well, most fellowship trained pain physicians were anesthesiologists up until maybe 10, 15 years ago. And now there's also physiatrists and neurologists that do pain fellowships, even family medicine, ER, doctor. So the field has changed somewhat, but traditionally most anesthesiologist were the ones doing pain because of their skillset with needle placement intervention, these kind of things. So that's how it evolved into a separate field essentially over time.

Dr. Fialkow:

It's putting very small needles, very sensitive places. Right.

Dr. Elbualy:

There you go. Sometimes big needles though

Dr. Fialkow:

Right? Lejo I want to spend a couple of minutes working in your space. Now, where do you see, from your experiences when you are addressing people with chronic pain, what are the kind of things you've seen and how have you helped those people? What do you offer? What do you offer people in the primary care setting?

Dr. Jose:

So in the primary care setting, we often see, we're the first people to see these patients. I think our biggest role is really just assessing a patient, assessing their comorbidities and trying to optimize them to eliminate what's actually truly causing the chronic pain versus what are other situations and positions they're putting themselves in. That's contributing to the pain. Now pain is often a cycle, like sometimes people will get at chronic pain, they'll get anxiety and depression from there. And you have to kind of try to break that cycle up. So our job is first to just optimize the patient, to try to help them with their depression, their anxiety now make them, encourage them to be exercising more, to take care of themselves. So, avoid drugs, avoid smoking.

Dr. Jose:

And once we're left with just, what's left is just the chronic pain. And then we can kind of attack that directly. Most of the patients we have here, they have a lot of comorbidities, they have diabetes, they have hypertension. Once we get these under control, a lot of their pain sensation does improve. And they're also in a better role to help actively manage their pain, to participate in physical therapy, to participate in going to their appointments. So a lot of what we see is really just trying to improve the whole lifestyle of the patient in order to put them in a better position, to again, manage their pain and break that cycle.

Dr. Fialkow:

I have two follow-ups to that. One is, and you've mentioned earlier and today, and just now, which is extremely profoundly important, how people with chronic pain can start becoming depressed and anxious, very much related. As well as people who are anxious and depressed, lower pain threshold. So they, they notice pains more. How important is that as part of your both assessment and treatment, are you able to assess that with people and then the pain will improve or go away is just part of it. I mean, speak a little bit, what your experiences are when you start assessing people's depression and or anxiety and how it's related.

Dr. Jose:

So again, we were talking with patients with chronic pain that have been living with this for months to years, it becomes very frustrating and there's a big limitation in what they can do in terms of physically with their social life, with their work life. And we find that depression can be a side effect of the chronic pain, but it can also contribute to the worsening of the experience of the chronic pain. So it's very important that we just not focus on specifically just the specific pain, but rather the entire lifestyle. And we, I find that most often when we do a multi-tiered approach of just helping them with their depression, helping them with their anxiety, encouraging them to make better choices in their life. They also respond to the pain tree, the pain management that we're also trying to provide much better. And overall, it's a great way to break that cycle. Sure.

Dr. Fialkow:

And another question at you, but anyone can chime in a particular pain syndrome, diabetic neuropathy, which we see quite frankly, certainly in our space. Can you speak a little bit about what that's like for people, how they present, and then what we can offer people who have first explain kind of what it is, and then what we can offer people who have the diabetic neuropathy.

Dr. Jose:

So, on my end, I see a lot of patients that come in they've had diabetes for a long time, diabetic neuropathy, and most often it's known as numb and tingling in the feet bilaterally, it becomes very debilitating in terms of it decreases their sleep quality. They're in constant pain. They basically, it can lead to a chronic depression almost. And in terms of the fact that they're not able to do the things that they used to be able to do, our job is to try to help them lessen that pain.

Dr. Jose:

We do offer different treatments. It starts with medications that we're actually used as anti-convulsants to help bring down the nerves' sensation there on top of that, we have to prevent it from getting worse. So it's just as important that we manage the diabetes and we get on top of it as quickly as possible. And I'm sure everybody else can probably give you a little bit more information on more specific treatments for it. But our job is really just to take care of the diabetes and to help mitigate the pain with small medication, just to give them some quality of life.

Dr. Fialkow:

But it is a chronic pain syndrome. As you noted for a specific population. An example of the pain is caused by obviously a nerve damage, but because of another medical condition, not something specific to the joint, we can talk about chronic back pain. One of the most common pain syndromes, most common reason. People go to the emergency room as acute back pain. But let's talk about other treatments out there. You guys are specialists using prescription medications, injections into the joint procedures as Seth mentioned, that are very sophisticated to actually eradicate the nerve function of pain. What about things that are out there say alternative medicine. And first let's speak about things like massage therapy and acupuncture, and then maybe address supplements or any over the counter preparations that have purported the health. I'll start with you Francisco. First, do you have any thoughts of these? Do you use these techniques we'll call them alternative medicines and subsequently supplements at all in your assessment of patients?

Francisco Garcia:

I do believe alternative medicine could be a com combined with our traditional ways of treating chronic pain as may not be the first line of treatment. We can definitely use it as a combination. One of the main questions that I get asked every day in my clinic is "should I use supplements?" "Should I use supplements such as glucosamine control and to prevent any flareups to prevent pain or to restore my cartilage?". So I give them a brief explanation that this combination of supplements may benefit, but there's not directly in clinically proven to provide all the, all the stuff that they're claimed to do.

Dr. Fialkow:

And in a sense, there's no proof they help. I mean, it's very interesting dialogue, which, maybe to our producers, we could do a Facebook live about placebos and whatnot, but if someone takes something safe and they feel better, even if it's not something that's actively making them feel better in a sense, isn't that the goal on the other hand, we want to be very careful if we're going to recommend something to let people know there's no data supporting it, as you just said with [inaudible 00:22:31] what about you, Seth? Do you see a role for alternative medicine therapies and subsequently any supplements or over the counter therapies that people may choose?

Dr. Elbualy:

I think it's sexy and people like it. The, the reality is if you do a little literature search on any of these things from creams to CBD oil, to THC, to stem cells, the evidence is extremely lacking, meaning it doesn't exist. So, my basic take, I tell patients that if they have money that they don't need, maybe they should give it to charity because I think that'd be a better use of the funds. And some of these alternative treatments, they've tried to work their way into the mainstream, like PRP and stem cells. They're really not. And they're really expensive. And I look at it as preying on people's desperation with chronic pain. So I'm not a fan.

Dr. Fialkow:

So I think the viewers can see a little skepticism of our experts here. Not a lot of no data, really supporting them, could be expensive people looking for that magical fix, but certainly if you're going to do it, make sure it's in compliment complimentary towards the proper medical evaluation and medical treatments that have been established to be helpful. And then Lejo, again, what's your, what's your situation in those, those types of tr alternative treatments and potentially supplements?

Dr. Jose:

I actually tend to agree with both the other to people. It's just mainly that I think people are coming in looking for an easy fix and they want me to support them on that. And I think the main thing I got to tell them is that it's not going to be easy. You have to go through the treatment that has proven to be effective for this. You have to take care of your health and it's not, you can't, there's no magic that will just solve this. Some of these patients, they'll try. They'll try everything except for what's clearly in front of them is just taking care of the issue that's in front of them. And sometimes we have to really have that hard conversation. Chronic pain is not something that you have to be fearful about coming into the doctor for it's, we have treatment options available for you. And the first step is not to just wait and just to come in and seek out help immediately when you need it

Dr. Fialkow:

To our listeners. If you have a comment or a suggestion for a future topic, please email us at baptisthealthtalk@baptisthealth.net that's baptisthealthtalk@baptisthealth.net. We'd love to hear from you. Thanks for listening and stay safe.

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