Pain Management

Episode 21 - Pain Management

Dr. Chehab:
Welcome to IBJI’s OrthoInform, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Shaab with Ortho Inform. Our goal is to provide you with an in-depth resource about common orthopedic conditions that we see everyday. Today it's my pleasure to welcome Dr. Brian Clay, who will be speaking to us about interventional pain management. As a brief introduction, Dr. Clay was born and raised in Chicago. He earned his medical degree from the University of Illinois at Chicago. Dr. Clay then entered his residency at Northwestern University School of Medicine and Physical Medicine and Rehabilitation. As part of his residency training, he also worked with the Rehabilitation Institute of Chicago, now known as the Shirley Ryan Ability Lab, one of the country's premier rehabilitation programs. Upon completion of his residency, Dr. Clay completed an additional year of fellowship training in anesthesia pain medicine at the University of Pittsburgh Medical Center. Dr. Clay has been with IBGI ever since the completion of his fellowship training. As a physiatrist, Dr. Clay is an expert in nerve, muscle, and bone, and the impact that injuries and illnesses can have on these vital organs. He has helped thousands of patients manage painful arthritic and post-traumatic conditions, and has also worked with patients who have suffered traumatic brain and spinal cord injuries. Dr. Clay has a selfless passion for others, and he is constantly exploring innovative practices and techniques to relieve the pain from which many patients suffer. He strives to restore the loss quality of life and provide the tools needed to optimize functional mobility for all patients. So, Brian, welcome to IBJI’s ortho Inform, and thank you for being here today.

Dr. Clay:
Thank you Dr. Chehab, I appreciate you having me.

Dr. Chehab:
You can call me Eric.
Dr. Clay:
Okay. Thanks, Eric.

Dr. Chehab:
So, Brian, there are no softballs here. And I'm gonna ask a very difficult question to start, which is, what is pain? Because when I think of pain, I think of anatomy as a surgeon and, and I think of disrupted anatomy, but then I think, well, where does the pain occur? Is it in the knee or is it in the brain? And, you know, why is it that some people who have one condition have a lot of pain, and another person with the same condition has no pain? And so what are your, what are your general thoughts on what pain is?

Dr. Clay:
Sure. So, you know, and that's a good question. I think that pain is, of course, is a subjective experience that patients have, and oftentimes the underlying pathology may differ from person to person. And ultimately, as a clinician, making a diagnosis is perhaps the most important step in determining what the source of pain is. For example, there is pain that can be visceral pain. There's pain that can be somatic pain due to actual injury, and there's chronic pain which, you know, is a, a different disease state that is distinct from other acute and subacute pain conditions.

Dr. Chehab:
Okay. So you talked about visceral pain, somatic pain, and the third one being chronic pain. Chronic pain. And they're different states of pain and so they're clearly lots of different inputs for pain, lots of different variables around pain, causes of pain. But in general, when people have pain, they know it. So, as a clinician, how do you know it?

Dr. Clay:
Well, and you know, again, that's the challenge of, of managing pain. You have to engage with the patient. You have to investigate potential causes of, you know, the source of the patient's complaint. And oftentimes we search for some sort of objective correlation. For instance, we'll get x-rays, we'll get MRIs and that'll help us determine, okay, well why is this person having back pain and leg pain? Oh, okay. The MRI shows there's a pinched nerve in the lower back, for instance. So some cases are as straightforward as that. And then there's the other patient who may have 20 years of chronic pain with diagnoses such as fibromyalgia, which is a complex diagnosis of chronic pain, of unknown etiology. And also there's patients who have several years of chronic rheumatoid arthritis that has then become chronic pain. And you really have to investigate each person on an individual basis to determine the source and to determine the correct pathway to manage that painful condition.

Dr. Chehab:
Yeah, it sounds incredibly complex because even though we have MRIs and x-rays that might identify an anatomic abnormality, the MRI doesn't say, this hurts. We have to make a couple of leaps to get to that point. Correct. I mean, you'll see some people who have a pinched nerve on an MRI and another person with a pinched nerve on a similar anatomy. But one person might have terrible pain and another person might have no pain. And we don't have any blood test or image that says, this is painful, this isn't.

Dr. Clay:
Yeah, that's right. And it's a pretty archaic way to investigate pain as you know, clinicians, what we do is ask patients, well, zero to 10, what's your pain? Zero, no pain. 10 out of 10 you're running around on fire. Okay, and so, but one person's 10 is another person's five. So then it becomes a very difficult thing to sort of objectify in terms of utilizing scales that we currently use. So it kind of makes it more of an investigational undertaking when patients present with, say, hip pain. And then the next question is, well, where is your hip? And then, you know, you kind of go down the road of investigating, you know, the clinical presentation. And that's usually gonna cue you into a potential source of pathology that you then investigate.

Dr. Chehab:
Okay, and you mentioned different tools in a toolbox. And as an orthopedic surgeon, my tool is generally a scalpel to help manage patients' painful conditions or disrupted anatomy. Take us through your toolbox of what you can offer patients to help with pain that has been chronic and longstanding.

Dr. Clay:
Sure, sure and I think we have to, I guess, make a distinction between the various types of pain management. I think as a subspecialty field, pain management sort of emerged as an interventional field. So for instance, there's interventional cardiology or interventional radiology. And the term interventional in medicine typically refers to a procedural based technique that one can utilize to diagnose or to manage an underlying pathology. And so in interventional pain, typically our toolbox involves some kind of procedure, which may be an injection or needle based procedure. There are also implantable devices that we utilize to manage pain for refractory cases, individuals who do not respond to the classic treatment, which typically would involve some sort of physical therapy management for medications or injections. And that's usually going to be part of the approach in managing either acute or chronic pain.

Dr. Chehab:
So just to summarize, you mentioned injections as an intervention that can help with pain. You mentioned implantable devices that can help with chronic pain. You mentioned medications that can help with pain. So let's go down the pathway of each of those. We can start with injections.

Dr. Clay:
Sure, sure. So the injections, so off, oftentimes patients come in and they've been referred for, let's say a quote unquote cortisone injection. So, then we have the discussion in terms of, okay, well, where's the source of the pain? And if an injection is appropriate, usually we would offer a sort of tailored approach. Right? So there's a number of different pathologic conditions, for instance, osteoarthritis like you treat every clinic, and myself as well, there are neurologic conditions such as neuropathy, which is a condition of a disease, state of nerves. And there are conditions where patients present with injuries to the intervertebral discs or disc herniations or spinal stenosis. And oftentimes there's overlap with how we treat these patients. So, the person who has chronic spinal stenosis in their seventies, for instance, we may offer the same sort of injection or spinal procedure that we would for someone who's in their twenties with a herniated disc that did not improve with physical therapy. So, you know, that's sort of one aspect of our initial treatment approach. And the idea here is the use of corticosteroid is a tool, but it's not the end all be all of the treatment. And so the real benefit of having these tools is that you can combine these tools into a comprehensive treatment program, and we typically would utilize other modalities such as physical therapy, for instance, to help aid us in managing these conditions.

Dr. Chehab:
So it, what's a great point that you brought up, physical therapy, another tool in the toolbox in addition to the injections, the implantable devices and the medications. And then what are some of the other tools that maybe we haven't covered? And just in terms of naming them, then we can go through them. Sure.

Dr. Clay:
So if we're talking about chronic pain you know, it's well delineated that chronic pain is a disease state. And so it's more of a sort of behavioral condition. Underlying chronic pain is more of a behavioral condition where you have underlying pathology in addition to chronic suffering, that then becomes a psychosomatic condition. So chronic suffering, for instance, can rewire the central nervous system. And in cases like individuals who suffered from pain for 20, 30 years typically, we'd also refer these patients to cognitive behavioral therapy, for instance, or pain psychology, for instance, in terms of complementary alternative approach to some of our other classic modalities that we use to treat this.

Dr. Chehab:
And so there's obviously this wide range of potential tools to help a patient who has pain, either acute pain or chronic pain. And, and, and these tools, it sounds like they are being used in combination, not uncommonly, and, and, and how to combine them as sort of the art of the medical practice that you perform. And so just kind of going through the next one, you mentioned implantable devices. What are those and how are they intended to help with the patient's pain?

Dr. Clay:
Sure. So many patients, when they come in, their goal obviously is to improve function and quality of life. And when we reach a point where patients have exhausted physical therapy, they've exhausted injections. We've tried a number of different pain medications with a miriad of side effects that patients can't tolerate. And so we get to a point where we're considering perhaps the service surgical intervention. And depending on the source of pathology, surgery can be a difficult step to take for some patients where we're not entirely sure what the outcome may be. For instance, and within pain management, we, we work very closely with the patient to determine what their goals are there are a few implantable devices that we typically utilize to improve that functional outcome most of them deal with conditions of the spine, which tend to be some of the more painful and complex pathological conditions.

Dr. Clay:
And for instance, one tool that we use is called spinal cord stimulation. And that's a device that's been around since the 1970s it's an implantable system that rewires essentially the sensory input of pain. So therefore someone with chronic peripheral neuropathy, for instance which is classically thought of as an untreatable condition, which with the progressive course within the pain management management scope, we can then implant the device and intervene on the pain feedback loop and sort of breakup that pathway. There are additional tools that we use to manage chronic spinal conditions that are refractory to injections, refractory to physical therapy and two of the procedures that I utilize in my clinic would be an interspinous spacer implant, which is also called Vertiflex. And that's a minimally invasive implant that we use for chronic spinal stenosis in the senior populations as an alternative to going on to have, you know,

Dr. Chehab:
A major spine surgery,

Dr. Clay:
Major spine surgery

Dr. Chehab:
Yeah, right.

 Dr. Clay:
Also, there is a procedure that we're utilizing called the mild procedure, and mild is an acronym that stands for minimally Invasive Lumbar Decompression. And this is also a minimally invasive tool done as an outpatient in our surgery centers, where we also treat chronic spinal stenosis for patients who, again, are not amenable to undergoing an extensive back surgery.

Dr. Chehab:
Okay, so these implants, it sounds like I are commonly used more as a, maybe a last line of defense, but certainly an effective intervention for patients suffering from what seemingly are chronic, untreatable painful conditions, which you actually can intervene and can break the feedback loop and can significantly alter the pain experience of the patient. And so as we move forward, we've talked about injections, we've talked about the implants, medications you mentioned. What are the range of medications, how are they helpful and what are the potential benefits and even potential side effects of medications for chronic pain?

Dr. Clay:
Sure, so the medications vary widely that we, that we utilize to treat pain as, as you well know. So there's very, there's, so there's various classes of medications for instance, anti-inflammatory drugs are usually going to be first line choices in addition to acetaminophen or Tylenol oftentimes I have patients just try over the counter remedies before we make the decision to prescribe pain medications. So in this environment that we're currently living in, there's an opioid epidemic as you well know. Yeah. And therefore, there's been an emphasis within our field to help stem the tide of the surge of opioid related deaths by, basically in our field, there is an emphasis on coming up with novel ways to manage pain that would not require utilization of opioids. That being said, quite a few patients honestly would benefit from low dose opioid management in addition to other functional rehabilitation programs. Oftentimes when patients come in, we think of multi modal approaches to treating pain with medications, for instance. So we may use a combination of anti-inflammatory medications such as Advil or medications that treat nerve pain such as gabapentin and utilizing these medications in combination does pose the risk of side effects. Some of the most common side effects from our pain medications would include sedation. GI side effects, discomfort, constipation, and, you know, we closely monitor patients for these side effects if we do have them on these pharmacologic interventions. But I think the most important thing to understand about managing pain with medications is that we should set goals and endpoints for the patient. Right. So it's always our goal to, if we start a patient on any medication, opioids or non-opioids, to eventually wean them off of it. And that becomes our challenge as we're managing these conditions for the patient. Because in some cases, unfortunately, patients will require these medications indefinitely.

Dr. Chehab:
Yeah, you know, the opioid epidemic has obviously affected so many people around the country, and it's shined a light on the, some of the potential harms of opiates, but they're clearly people who benefit from it. And I don't envy you or any other pain management specialist who is walking that fine line of how I can provide the benefit of the opiates to a patient with the potential side effects that can come from it. And obviously the epidemic has really shined a light on it, probably to the benefit in some ways that people are much more careful with the use of opiates, but also maybe to the detriment, because we've become a lot more stringent about who we are giving opiates to. And it, and it, it kind of cuts both ways of being more careful with it, but also maybe inappropriately withholding it from patients who might benefit. So, I don't know how you guys walk that tightrope.

Dr. Clay:
Yeah, and it is challenging, I think that you have to have the discussion with the patient or the patient and the patient's family. And again, I think if everyone is on the same page as far as the goal of the management with opioids, and the one outcome that I look for when patients who are on chronic opioids is the functional aspect of, you know, what that medicine allows them to do. Oftentimes individuals who are on say, chronic opioids will require these medications for function and whereas without the medications, they may be functionally limited due to the intensity of the pain. Yeah. And so that then, you know, becomes a risk benefit question. And in some cases it's necessary to manage these patients with opioids in order to improve their function.

Dr. Chehab:
So, yeah and any other, you mentioned nerve medications like gabapentin, any other types of medications that you think can be helpful for patients or things like antidepressants helpful for patients pain or any other class of medications? Sure.

Dr. Clay:
Yeah. So in terms of the full gamut of pain medications, we typically would use a combination of a nerve pain agent, such as gabapentin or anti-inflammatory pain medications such as Advil or Aleve. And the anti-depressants that we use typically would involve some sort of serotonin or norepinephrine reuptake inhibitors,one of the more common ones would be duloxetine, also known as Cymbalta which has some nerve pain management properties. And the benefit of using the antidepressants is that oftentimes with chronic pain, there's a mood component that we also address with the antidepressant modalities.

Dr. Chehab:
Okay. So that's a great overview of the medications, anti-inflammatories, nerve pain medications like gabapentin, some of the opioid medications, some of the antidepressant medications would also have a nerve impact, seem to be a pretty good set of possible medications that you can mix and match with patients to improve function and minimize side effects. So, and then moving on to the next category in the toolbox, you had mentioned physical therapy. How is physical therapy helpful and beneficial for pain management? Obviously, we can make a pretty easily why it be helpful for function and mobility, but how does it help with pain management.

Dr. Clay:
With individuals who have pain? There's some chronic disability or dysfunction, and once we're able to manage the pain, then we're stuck with the fallout from, you know, the weakness that comes with chronic pain or even acute pain. And we utilize physical therapy as a tool to help patients recover some of that functional loss that inevitably occurs when people suffer

Dr. Chehab:
Inhibited by their pain

Dr. Clay:
Absolutely.

Dr. Chehab:
Yeah and so the therapy is focused on recovery of strength, recovery flexibility, and, and is it in of itself? Is motion a pain reliever? Is there some sort of, you know, hormone that gets released with, with movement? Is there some sort of benefit to the muscle activation? Is there any, I'm just curious on a totally sort of layperson view of this, if the therapy itself induces some sort of biochemical response that allows for the pain to be reduced?

Dr. Clay:
Yeah, I mean, and I think that there is some component of an endorphin release if you're participating in physical therapy, if you're improving your mobility range of motion, it allows you to do other activities outside of physical therapy as well go for walks you know, participate in hobbies, participate in sports activities, for instance. And so that initial therapeutic approach then sort of leads to other quality of life goals that patients can achieve through therapy. Yeah.

Dr. Chehab:
And I think we're kind of alluding also to the mental health aspect of pain and pain management. And you mentioned another tool in the toolbox being cognitive behavioral therapy or modalities like that. So let's explore that a little bit. How do you use your colleagues who do cognitive behavioral therapy? Do you do it yourself?

Dr. Clay:
I don't, I typically would refer patients for pain psychology evaluation. So there, yeah. There are psychologists who have special specialization in cognitive behavioral therapy for pain management. And, you know, again, we are looking for tools for patients to make this a comprehensive approach, for instance. Right. So for instance, at Illinois Bone and Joint, we have the ortho health program, and we have our obesity medicine specialists that are part of the program as well. So if there's a patient who we identify as being functionally limited due to their body habit as for instance, then we'll refer them to the ortho health program that we have here. And that becomes part of the interdisciplinary approach. So when you're talking about cognitive behavioral therapy, biofeedback kind of falls under that umbrella of an interdisciplinary approach to managing pain.

Dr. Chehab:
Yeah. So, it sounds like it's the rare patient who gets one of these tools that solves their problem, it sounds like many patients or the majority of patients will require some combination of the use of these tools. Is that correct?

Dr. Clay:
Yes. correct

Dr. Chehab:
And then again, the art of it is sort of selecting which tools, and my guess is it's not a straight line.
Dr. Clay:
It, it can be a little bit of a gray area. I think each case is unique. Each case is different from, you know, based on the pathology, based on the age, the gender of the patient. Again, the BMI, you know, there's so many factors that one has to examine prior to, you know, making a treatment plan for a patient that we think will be effective. Yeah.

Dr. Chehab:
Yeah. And so what are the outcomes that someone who's been experiencing pain, who then is able to have the benefit of your care and your colleagues' care? Are they, is the expectation set that you will eliminate their pain completely? Or is it more that let's get this manageable so that you can live a functional life? Like, I mean, obviously the goal would be to get rid of it like that's, I think everybody's dream. What are some of the realistic expectations and outcomes for working interventional pain management?

Dr. Clay:
Yeah. I think you're correct there. There's always the home run, you know, where you knock it out, the park and the pain goes away and it never comes back. And, you know, that's sort of the ideal outcome. But realistically you know, we try to work with the patients to give them as many twos to optimize their functional outcomes. Right, so for instance, a patient may come through their doors at Illinois Bone and Joint Institute with back pain, for instance, and we take them through our, you know, protocols and our algorithms of managing PT with medications or interventions. And then when everything's said and done and the dust settles, you know, they may find that they feel stronger, they may find that they're able to walk longer. They're able to walk longer distances, they're sleeping better, their mood is better. But despite that, they still have the underlying pain. It's just, it's just more manageable and it doesn't interfere with their function and quality of life. So, you know, the goal is to, to save lifestyles. And that's, you know, and that's essentially every case that comes in the door. That's, you know, where my focus is.

Dr. Chehab:
That's the goal, I mean, I find it just such a fascinating topic because pain is experienced so differently by people and shaped by their experience, shaped by their expectations. And you know, you could, you could go on forever and ever discussing this. I don't know. What are some of your, your, your overarching thoughts? You said lifestyle, getting back is a big deal. If I could just kind of probe this, what do you think is at the root of a patient who has been suffering from chronic pain? Is it one thing or multiple things? Is it one injury? Is it an accumulation, or is it any of the above?

Dr. Clay:
Well, yeah, And chronic pain, again, is usually a multifactorial condition. I mean, it can start with initial injury that then spirals into a myriad of other injuries that are consequences of the initial injury. So you may have a, disc injury in the neck, for instance, and then you subsequently develop a problem in the shoulder. And so therefore, sort of following the pathology initially is the most important step to preventing chronic pain initially. So, I think that when you get to a point where you've had years and years of pain, you have to sort of peel back the onion and do a retrospective analysis and see what was done in the past that has led the patient to this point in time.

Dr. Chehab:
Okay, and in the future treatments of pain management, do you foresee a magic bullet medication, a magic bullet intervention? Or do you think it will typically always be some sort of multimodality treatment to help, you know, patients manage their discomfort and manage their chronic pain?

Dr. Clay:
So, that's a great question, and I think the most exciting aspect of medicine now is the regenerative medicine component. So we're investigating novel ways to regenerate pathologic states, right? So utilization of stem cell, platelet rich plasma, laser technology, wave technology, you're seeing a lot of these new regenerative medicine products come on the market. And while the research is still ongoing, it's promising for the future in that if we could actually reverse some of these conditions that have classically been progressive and degenerative then moving forward into the next generations, I think, you know, we'll see less and less of the chronic disability that comes from conditions such as osteoarthritis or neuropathy.

Dr. Chehab:
Yeah, no, that's an exciting area and one that holds a ton of promise in the field of restoring orthopedic kinetics and orthopedic joints, and also obviously in preventing pain that you treat. Any other parting thoughts? Anything that you wanna convey to the listener that would be helpful? And particularly for our listeners who may be suffering from chronically painful conditions, or who need interventional pain management?

Dr. Clay:
So, in terms of partying words, I think that in individuals in discussing chronic pain, it's important to understand that there are a number of tools available for these patients, which may involve, you know, just having a second look at their case, you know, implementing the appropriate treatment protocols and getting them resources to manage the pain outside of just the classic medications, opioids, non-opioids, injections, and so forth. And I think moving forward in the future, you're gonna see a lot more interdisciplinary approaches available to manage these conditions. So I think that the field is exciting. I think that there are many advances that are being made in the field and that, yeah, I would encourage patients to seek out treatment and to understand that they're not alone.

Dr. Chehab:
Our guest today is Dr. Brian Clay. Brian, thanks so much for being here today.

Dr. Clay:
Yeah. Thanks so much for having me, Eric. I really appreciated this opportunity and hopefully this reaches someone out there who needs our assistance.