Transcript Pain Management - Foma District 2

Pain
Management:
Head to Toe Analysis
Ferdinand Formoso, D.O.
About me
 Bachelors, University of Buffalo (Psychology)
 Doctorate, NYCOM
 Residency, St. Barnabas Hospital

General Surgery
 Residency, Temple

University
PM&R
 Fellowship, Temple University

Pain Medicine
 Founder, Coastal Spine
& Pain Center
Disclosures
 Pfizer
speaker bureau
Objectives
 Pain medicine overview,
 When/why to refer
physician training
to a pain specialist
 What do we (pain specialists) do and how do we
do it?
 Why is pain management important?
Introduction
•
Pain is recognized as one of the greatest health
care crises of our time
•
$560-635 billion annually in total costs
•
•
•
More than any other health issue
#1 reason for missed work in USA
One of the most common reasons patients seek
medical attention
•
2 of the top 5 reasons to seek medical care
•
Joint pain, Low back pain
Introduction

Pain is a presenting symptom for many
diseases/syndromes

Pain – as the disease

CRPS, Fibromyalgia, Chronic low back pain?, IC?

Study of pain is currently one of the most academically
active endeavors - PubMed search: 132,928 studies!

Pain Medicine is emerging as an independent medical
specialty
Pain Medicine: Training
 What is Pain Management?

“Officially” a subspecialty within:
 Anesthesiology
 Physical Medicine & Rehabilitation
 Neurology
 Psychiatry
 Fellowship training in Pain Medicine



1 year post-residency
“Interventional” and “non-interventional” training
American Board of Pain Medicine residency
proposal
Pain Medicine: Training
 Pain Physicians, are they created equal?

Board Certified:
 Anesthesiologists
 Physiatrists (PM&R)
 Neurologists/Psychiatrists
 Other specialists


Non Board Certified
M.D. / D.O.
When to refer
 Acute Conditions




At first presentation
After a trial of NSAIDs/basic meds, rest (2-3 weeks)
After above plus trial of PT, basic imaging (3-6
weeks)
After above plus advanced imaging (6-12 weeks)
 Chronic conditions

Sooner is better
When to refer
 Timing, diagnosis dependent




Lumbar strain
Acute radiculopathy
Shingles outbreak
Chronic low back pain
 Timing, referring physician dependent



Training
Comfort with prescribing pain medications
Awareness of pain physician capabilities
Why refer?
 Acute conditions:


Quick recognition of the diagnosis leads to better
outcomes (CRPS, PHN)
Acute pain evolves into chronic pain
 Chronic conditions:



Multitude of treatment options
Expertise/experience gives us the tools to treat
these challenging issues
Patients don’t “have to live with it”
What do Pain Physicians do?
Detailed
History
Physical
Exam
Whole
Patient
Psychology/
Behavior
Work/Living
Environment
What do Pain Physicians do?
 Pain physicians can offer
more than most realize
Physical
Medicine
Injections
Conservative
treatment
Surgery
Medications
Psychology
What do Pain Physicians do?
 Physical Medicine:

Structural optimization
 Kinetic chain
 Correction of leg
length discrepancies
 Bracing

Strengthening and flexibility
 General
and site specific
 Home exercise education

Work/home environment
 Posture
 Workstation adjustments
 Injury prevention
What do Pain Physicians do?
 Injections:
Intraspinal
Procedures:
Epidurals,
Sympathetic
blocks, SCS, IT
pumps
Structural Spine
Procedures:
Facets, SIJs
Minor Procedures: myofascial,
joints, tendons, ligaments,
peripheral nerves
Options?
Injections
 Genicular Nerve blocks/Ablations
What do Pain Physicians do?
 Medications:
 Opiates waiting for the
patients at the door?
 Combination therapy:


NSAIDs/APAP
Neuropathic agents
 Antidepressants
 Anticonvulsants

Opiates
 Triptans
 Muscle relaxants
 Benzodiazepines
 short/long acting
 Sedatives
 buprenorphine
 Topical
 guidelines/legal concerns
Medicines
What do Pain Physicians do?
 Psychology:

Gate Control Theory (Melzack and Wall, 1965)
 Peripheral
stimuli interact with cortical variables
 Cortical/central potentiating/moderating effects

Neuromatrix Theory (Melzack, 1999)
 Genetically
determined, modified by sensory input/learning
 Neural impulses can initiate from stimuli or centrally
 Pain suppression can occur with sensory and evaluative
processes
Conclusion
 Treatment of pain is a complex
endeavor if done right


Should involve a multidisciplinary
approach
Injection therapy involves skill,
proper training
 Patient

Meds
Injections
Physical/Cognitive
Therapy
selection is critical
Medication choices are numerous
 Combination therapy is
complicated
 Patient safety
 Legal implications
best, but
Good Outcomes
Ferdinand Formoso, D.O.
Kenneth Powell, D.O.
Alan Miller, M.D.
John Hunt, M.D.
Patrick Burns, D.O.
Manuel Lopez, M.D.
Scott Schimpff, M.D.
F. Lee Irwin, M.D.
Eli Loch, D.O.
Haitao Zhang, M.D., Ph.D.
Christopher Manees, M.D.
Michael Greene, D.O.
Luiz Massa, M.D.
East Park
Beaches
Orange Park
Northside
Riverside
Fernandina Beach
Hilliard
Bartram Park
Middleburg